Postoperative Analgesia and Recovery with Liposomal Bupivacaine TAP/RSB Block in Elderly Patients Undergoing Laparoscopic Inguinal Hernia Repair: A Randomized Controlled Trial.

BACKGROUND: Older adults undergoing laparoscopic transabdominal preperitoneal (TAPP) hernia repair often experience inadequate analgesia and delayed mobilization. We tested the hypothesis that dual-plane abdominal wall blocks (transversus abdominis plane + rectus sheath block, TAP+RSB) using liposomal bupivacaine (LB) improve opioid-sparing and recovery versus standard bupivacaine (BP) or no block. METHODS: In this single-center, randomized, three-arm trial, 147 patients aged ≥70 years were assigned 1:1:1 to LB‑TAP+RSB (LB group, n=49), BP‑TAP+RSB (BP group, n=49), or no block (control, n=49). Anaesthesia was standardised to maintain BIS 40-60. The primary outcome was 48‑hour opioid consumption (intravenous morphine equivalents). Secondary outcomes included time to first rescue analgesia, pain scores at rest/on movement, time to ambulation, time to extubation, length of stay, and adverse events. RESULTS: Total opioid use was significantly lower in both block groups versus control (BP: -5.53 mg, 95% CI -8.08 to -2.99; LB: -7.24 mg, 95% CI -9.80 to -4.69). Fewer LB patients needed early rescue analgesia than controls (2.0% vs 18.4%, OR 0.10, 95% CI 0.01-0.84). At 8 h, rest pain was lower with LB (P=0.007). Ambulation time was shortest with LB (14.1±2.5 h) compared with BP (16.7±6.5 h) and control (20.0±6.2 h) (both P≤0.006). Extubation occurred earlier in block groups (LB/BP median 2 min vs control 6 min, P<0.001). Hospital stay was shorter with blocks (median 3 vs 4 days, P<0.001). Adverse events did not differ between groups. CONCLUSION: Dual-plane TAP+RSB, particularly with LB, reduces opioid need and speeds recovery in older TAPP patients, supporting its use in ERAS pathways.