Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)

Background and Aims Long-acting spinal anaesthesia with high-dose intrathecal opiates has become the standard for enhanced recovery programmes for colorectal cancer surgery. Our department previously demonstrated that short-acting spinal anaesthesia using prilocaine combined with fascial plane blocks and catheters was effective, with reduced haemodynamic instability and earlier patient mobilisation. We now describe a case series utilising a novel adaptation to this approach, with liposomal bupivacaine (Exparel) fascial plane infiltration.

Methods Fifteen patients undergoing major laparoscopic colorectal surgery were included between October 2022 and May 2023. All patients received 3.0ml of intrathecal 2% hyperbaric prilocaine combined with 100-200mcg of preservative-free morphine. In addition patients received ultrasound-guided lateral transversus abdominis plane (TAP) and rectus sheath fascial plane infiltration with a local anaesthetic admixture of 20mls of 13.3mg/ml Exparel combined with 40mls of 0.25% levobupivacaine and 20ml normal saline. All patients also received 1g paracetamol, and either parecoxib 40mg or ibuprofen 400mg intravenously (if not otherwise contraindicated).

Results Intra-operatively patients behaved with haemodynamic stability, with no patients requiring vasopressor support post-operatively. In the recovery area, all patients were able to sit up and ambulate with an average post-operative pain score of 0.25. Mean length of hospital stay was was 10.3 days (7.5 after removing one major outlier) and over half of patients did not require HDU monitoring post-operatively at all.

Conclusions The combined use of Exparel fascial plane blocks with short-acting spinal reduces the opiate requirement in the peri-operative management of laparoscopic colorectal surgery. Excellent long duration analgesia and haemodynamic stability is provided with a minimal side effect profile.

Attachment: Exparel case series local research committee approval.pdf