Anesthesia for open inguinal hernia repair with ultrasound-guided transversus abdominis plane block in a high-risk elderly patient: Case report

Kaya, C.; Genc, C.

doi:10.1016/j.redare.2020.01.015

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Anatomically, the anterior branches of the lower thoracic spinal nerves (intercostal [T7-11], subcostal [T12] and iliohypogastric/ilioinguinal [L1] nerves) innervate the anterolateral abdominal wall. The anterior branches (T7-12) run through the neurovascular plane between the internal oblique and transverse muscles, and bifurcate into the cutaneous and anterior branches (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The L1 root bifurcates into the iliohypogastric/ilioinguinal nerve branches, which contribute to the innervation of the inguinal region. The TAP block provides a certain degree of somatic block, but does not reach the sympathetic afferents, and therefore does not prevent visceral pain during abdominal surgery.<a class="elsevierStyleCrossRef" href="#bib0040">3</a> However, case reports on the use of TAP block plus sedation for anaesthesia in open gastrostomy, open appendectomy, emergency laparotomy and paediatric vesicostomy encouraged us to use this technique in surgical anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0045">4</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>We describe the case of a 77-year-old man, height 175cm, weight 85kg, high risk, who underwent open inguinal hernia repair with ultrasound-guided unilateral TAP block plus intravenous (IV) infusion of remifentanil. The patient suffered from coronary artery disease, hypertension, and congestive heart failure (NYHA class III). Labs were within normal limits, but the patient's electrocardiogram showed atrial fibrillation, and the echocardiography showed a left ventricular ejection fraction of 25%, pulmonary artery pressure of 40mmHg, and moderate to severe tricuspid-mitral regurgitation. High-resolution chest CT scan showed diffuse tubular bronchiectasis and vitreous nodules in the lungs. The patient was classed as IV on the American Society of Anesthesiologists (ASA) physical status scale. Informed consent was obtained from the patient. After standard monitoring and before administering the block, infusion of 0.05–0.1μg/kg/min IV remifentanil was started to allow verbal communication. The patient was placed in a supine position. The block was administered using a high-frequency linear ultrasound transducer (MyLab® Five, Esaote, Florence, Italy) placed between the subcostal margin and the iliac crest, at the level of the umbilicus, to visualise the external oblique, internal oblique and TAP muscles, as well as the peritoneal cavity (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The nerve block needle (100mm, 21G short bezel; Stimuplex®, B. Braun, Melsungen, Germany) was inserted in plane in an anterolateral to posterior direction. After checking for flashback, 20ml of 0.5% bupivacaine was injected. The surgical procedure began after evaluating the sensory block in the T10-L1 dermatomes. Intraoperative abdominal pain that occurred during hernial sac dissection was treated with remifentanil (0.025–0.05μg/kg/min) and IV ketamine in divided doses (25mg total). Intraoperative haemodynamic parameters were similar to preoperative values. The patient was admitted to the intensive care unit for postoperative monitoring, and 16h later was transferred to the general surgery ward, with no sign of complications. No incidents have yet been reported (1 month after surgery).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>In ultrasound-guided unilateral TAP block, LA is administered in the mid-axillary line, providing anaesthesia to the lower abdominal wall from the midline to the midclavicular line. This technique is only useful for periumbilical and infraumbilical interventions, since the LA does not spread above T10. However, the spread of LA around the ilioinguinal/iliohypogastric nerve and the internal oblique muscle cannot always be predicted due to anatomical variations, and a separate ilioinguinal/iliohypogastric nerve block is sometimes required, particularly when the hernial incision includes the T12-L1 dermatome.<a class="elsevierStyleCrossRef" href="#bib0040">3</a>Although few TAP block-related complications have been reported, some cases of intraoperative bradycardia in response to IV atropine have been published (0.5mg). Other complications include intraperitoneal injection, colon and liver injury, seizures, ventricular arrhythmia, and transient paralysis of the femoral nerve.<a class="elsevierStyleCrossRef" href="#bib0040">3</a> Considering the brief analgesic effect (4–12h) of a single injection of LA in the TAP block, adding dexamethasone to this LA, which we do not use in our clinical practice, could increase the quality and duration of analgesia, and reduce the opioid consumption and opioid-related complications.<a class="elsevierStyleCrossRef" href="#bib0050">5</a>Therefore, our case has shown that open inguinal hernia repair can be successfully performed by administering IV remifentanil combined with unilateral TAP block. Ultrasound-guided TAP block is a safe, effective anaesthetic option in high-risk patients scheduled for lower abdominal surgery." 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Sivarajan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2147/LRA.S93673" "Revista" => array:6 [ "tituloSerie" => "Local Reg Anesth" "fecha" => "2016" "volumen" => "9" "paginaInicial" => "7" "paginaFinal" => "12" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26848274" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transversus abdominal plane block as a sole anesthetic technique for abdominal wall hematoma drainage" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N. Varela" 1 => "M. Golvano" 2 => "P. Monedero" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2015.12.001" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2016" "volumen" => "63" "paginaInicial" => "487" "paginaFinal" => "490" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26774971" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transversus abdominis plane block: an updated review of anatomy and techniques" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H.C. Tsai" 1 => "T. Yoshida" 2 => "T.Y. Chuang" 3 => "S.F. Yang" 4 => "C.C. Chang" 5 => "H.Y. Yao" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1155/2017/8284363" "Revista" => array:4 [ "tituloSerie" => "Biomed Res Int" "fecha" => "2017" "volumen" => "2017" "paginaInicial" => "12" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transversus abdominus blocks instead of general anesthesia in a child" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. AlGhamdi" 1 => "M. AlSuhebani" 2 => "J.D. Tobias" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/sja.SJA_433_19" "Revista" => array:6 [ "tituloSerie" => "Saudi J Anaesth" "fecha" => "2019" "volumen" => "13" "paginaInicial" => "377" "paginaFinal" => "380" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31572089" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plain (TAP) block for analgesia after abdominal surgery: a systematic review and meta-analysis of randomized controlled trials" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D. Zhang" 1 => "C. Zhou" 2 => "D. Wei" 3 => "L. Ge" 4 => "Q. Li" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0209646" "Revista" => array:5 [ "tituloSerie" => "PLOS ONE" "fecha" => "2019" "volumen" => "14" "paginaInicial" => "e0209646" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30620730" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006700000010/v1_202012131408/S2341192920301530/v1_202012131408/en/main.assets" "Apartado" => array:4 [ "identificador" => "66474" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Director" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006700000010/v1_202012131408/S2341192920301530/v1_202012131408/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192920301530?idApp=UINPBA00004N"]

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Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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Vol. 67. Issue 10.

Pages 572-574 (December 2020)

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