|Year : 2019 | Volume
| Issue : 1 | Page : 60-63
Ultrasound-guided bilateral subcostal TAP block for epigastric hernia repair: A case series
Pradeep Bhatia1, Pooja Bihani1, Swati Chhabra1, Vandana Sharma2, Rishabh Jaju1
1 Department of Anaesthesiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Anaesthesiology, S. N. Medical College, Jodhpur, Rajasthan, India
|Date of Web Publication||10-Jan-2019|
Dr. Pooja Bihani
Department of Anaesthesiology, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bhatia P, Bihani P, Chhabra S, Sharma V, Jaju R. Ultrasound-guided bilateral subcostal TAP block for epigastric hernia repair: A case series. Indian J Anaesth 2019;63:60-3
|How to cite this URL:|
Bhatia P, Bihani P, Chhabra S, Sharma V, Jaju R. Ultrasound-guided bilateral subcostal TAP block for epigastric hernia repair: A case series. Indian J Anaesth [serial online] 2019 [cited 2019 Jun 18];63:60-3. Available from: http://www.ijaweb.org/text.asp?2019/63/1/60/249789
| Introduction|| |
The transversus abdominis plane (TAP) block is a field block and it involves myocutaneous nerves supplying the anterior abdominal wall (T6 to L1). It can be performed through the classical posterior or subcostal approaches. It is commonly used as an adjunct to perioperative analgesia in a wide variety of surgeries, but reports on its role as a sole anaesthetic technique are scarce.,, We present a case series of epigastric hernia repair where subcostal TAP block was used as a sole anaesthetic technique.
| Methods|| |
After permission from Institutional Ethical Committee, we enrolled American Society of Anesthesiologists (ASA) Grade I and II patients posted for elective epigastric hernia repair. Obese patients, patients with a large hernia containing bowel, patients with local anaesthetic allergy and patients who refused to consent were excluded from the study. After written and informed consent, all patients underwent preanaesthetic evaluation. They were explained about the block procedure and ensured that any discomfort or pain occurring during surgery would be dealt with intravenous medications or conversion to general anaesthesia if required. They were informed to rank pain severity on 0 to 100 point scale in the postoperative period.
Under all aseptic precautions, bilateral ultrasound (USG)-guided subcostal TAP block was given using USG system (GE Healthcare, USA) with a high-frequency (6–13 MHz) linear array transducer by the technique described by Hebbard et al. The USG probe was placed obliquely over the anterior abdominal wall along the subcostal margin near the midline and moved laterally to identify the origin of transverse abdominis muscle posterior to rectus abdominis. With in-plane technique, a 22G 100-mm long block needle (SonoPlex™, PAJUNK, Germany) was advanced, and ropivacaine 0.5%, 15 mL with 1 μg/kg fentanyl, was injected on either side [Figure 1].
|Figure 1: Arrows indicating local anaesthetic deposition in the transverse abdominis plane; probe placement shown in the inset. RA: Rectus abdominis, TA: Transverse abdominis|
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After confirmation of sensory block, the surgery was started. Heart rate, blood pressure and SpO2 were recorded. Any discomfort while pulling of hernia content or pain during the procedure was managed with an intravenous bolus of 1 μg/kg fentanyl. As a backup plan, preparation for administration for general anaesthesia was done, if the patient complained of discomfort or pain even after three boluses of fentanyl. After surgery, the patients were shifted to the recovery room and were observed for pain, postoperative nausea and vomiting (PONV) or any other complications. After 24 h of surgery, patients were discharged home.
Postoperative pain severity was measured using a Visual Analogue Scale (VAS) between 'no pain' (0) and 'very severe pain' (10) and was recorded 2 hourly for the first 6 h and then 6 hourly up to 24 h. If VAS score reached more than 4, rescue analgesia with paracetamol 15 mg/kg IV was given. The duration of analgesia was considered as the time interval from immediate postoperative period until VAS score approaches 4. PONV was measured using a simple categorical system, that is, verbal descriptive scale (0 = none, 1 = mild, 2 = moderate, 3 = severe). Surgeons were also asked to grade the surgical conditions as excellent, satisfactory or poor. Data were collected by an independent observer, and the results were described as median, interquartile range and percentage. A written and informed consent was taken from all the patients for possible publication of their data for research purpose.
| Results|| |
Ten patients were enrolled in the study, but two were excluded as they did not give consent for the procedure. Demographic characteristics and intraoperative parameters of patients are summarised in [Table 1]. Haemodynamic parameters remained within normal limits throughout the intraoperative period in all the patients. Block was successful in all the patients and none of the patients required general anaesthesia. Two patients were administered intraoperative fentanyl bolus (one and two boluses, respectively). Surgical conditions were reported as excellent in two patients and satisfactory in the rest of the patients. Postoperative median VAS score was below 3 in 75% of the patients and two patients required paracetamol supplementation in the postoperative period at 6 and 12 h, respectively. The median duration of analgesia was 24 h (range: 6–24 h), after which the patients were discharged home. None of the patients reported PONV or any other complications.
| Discussion|| |
TAP block is an abdominal field block acting on the myocutaneous nerve supply of the anterior abdominal wall. Subcostal approach blocks higher levels of sensory nerves ranging from T6 to T10 and therefore appropriate for surgeries with supraumbilical incision.
Although subcostal TAP block has been demonstrated to be successful as a part of multimodal analgesia following various upper abdominal hepatobiliary and gastrointestinal surgeries,,,, reports on its role as surgical anaesthesia are limited. Hasan et al. reported a case series of five patients who were operated for open gastrostomy under bilateral subcostal TAP block, and only one patient required local anaesthetic injection on the upper end of incision. Lee et al. reported a case of high-risk elderly patient operated for open gastrostomy under left subcostal TAP block. A case of large incisional epigastric hernia repair in a high-risk cardiac patient (ASA III), which was operated under bilateral subcostal TAP block, was reported by Bihani et al.
There are several advantages of subcostal TAP block for epigastric hernia repair when compared with other possible anaesthesia techniques. The reduced requirement of opioids and thus decreased incidences of PONV and respiratory depression are the main reasons that subcostal TAP block scores over monitored anaesthesia care or general anaesthesia. Since the TAP might act as a depot to local anaesthetics, the duration of analgesia is much prolonged compared with LA infiltration. The placement of the catheter and continuous infusion can further prolong the analgesia.
When compared with central neuraxial blockade, the advantages are the absence of sympathetic and motor block and avoidance of related side effects and complications.
In our case series, only two patients required IV fentanyl supplementation, and the duration of analgesia in most of the patients was 12–24 h postoperatively. Although all the study patients were ASA physical status I or II, subcostal TAP block may be particularly advantageous in ASA 3 and 4 by reducing the opioids' requirements. Inability to block visceral component of pain is also a disadvantage of TAP block.
The limitation of our study is that we involved ASA Grade I and II patients with small-sized hernia containing omentum. Obese patients were not included as the block was difficult to perform. A large hernia with intestinal content may require supplemental analgesic drugs. Since this is an observational series of a small number of cases, randomised comparative prospective trials may be conducted to prove its efficacy over LA infiltration or monitored anaesthesia care.
| Conclusion|| |
Subcostal TAP block can be an alternative to monitored anaesthesia care or general anaesthesia for epigastric hernia repair.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Hebbard P, Barrington MJ, Vasey C. Cade. Ultrasound-guided continuous oblique subcostal transversus abdominis plane block. Reg Anesth Pain Med 2010;35:436-41
Kerai S, Dabas N, Sehrawat L, Gupta N. Transversus abdominis plane block as sole anaesthetic technique for inguinal hernia repair in two patients having complex medical conditions. Indian J Anesth 2015;59:754-6.
Hasan MS, Ling KU, Vijayan R, Mamat M, Chin KF. Open gastrostomy under ultrasound-guided bilateral oblique subcostal transversus abdominis plane block: A case series. Eur J Anaesthesiol 2011;28:888-9.
Lee AR, Choe YS. Anesthesia experience for open gastrostomy with ultrasound-guided unilateral subcostal transversus abdominis plane block in a high risk elderly patient: A case report. Anesth Pain Med 2015;5:e2490.
Petersen PL, Mathiesen O, Torup H, Dahl JB. The transversus abdominis plane block: A valuable option for postoperative analgesia? A topical review. Acta Anaesthesiol Scand2010;54:529-35.
Mukherjee A, Guhabiswas R, Kshirsagar S, Rupert E. Ultrasound guided oblique subcostal transversus abdominis plane block: An observational study on a new and promising analgesic technique. Indian J Anaesth 2016;60:284-6.
] [Full text]
Niraj G, Kelkar A, Fox A. Oblique subcostal TAP catheters: An alternative to epidural analgesia after upper abdominal surgery? Anaesthesia 2009;64:1137-40.
Ibrahim M, Shamaa H. Efficacy of ultrasound-guided oblique subcostal transversus abdominis plane block after laparoscopic sleeve gastrectomy: A double blind, randomized, placebo controlled study. Egypt J Anesth 2014;30:285-92.
Bihani P, Bhatia P, Chhabra S, Gangwar P. Can ultrasound-guided subcostal transverse abdominis plane block be used as sole anesthetic technique? Saudi J Anaesth 2017;11:111-3.
] [Full text]