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Postoperative pain
management in patients with cardiac and other multiple co-morbidities
undergoing lower abdominal surgeries like abdominal hysterectomy, inguinal
hernia repair, prostatectomy, caesarean delivery poses a challenge to
anesthetists. Many techniques have been tried, like Transversus Abdominis Plane
block (TAP), paravertebral block, quadratus lumborum plane block, inguinal
field block, continuous epidural anesthesia are a few.
In this review
article, the effectiveness of TAP block as a sole anesthetic for inguinal
hernia repair and postoperative pain management in patients undergoing lower
abdominal surgeries have been highlighted.
Keywords: TAP block, Inguinal hernia, Lower abdominal surgeries
INTRODUCTION
TAP (Transversus Abdominis Plane) block is a newly introduced regional
anesthetic technique where the local anesthetic is deposited in the potential
space between the internal oblique and transversus abdominis muscle in the
abdominal wall. It has been used in patients undergoing Caesarean delivery,
total abdominal hysterectomy, appendectomy, inguinal hernia repair, and also
radical prostatectomy and found to provide excellent analgesia postoperatively
[1,2].
Transvesus Abdominis Plane is formed by the subcostal margin, from 9th
to 12th costal cartilage, continued into the border of the
latissimus dorsi superiorly, inguinal ligament, iliac crest below and linea
semilunaris anteriorly. Anterior rami of T7-T11 nerves continue from
intercostal space to enter the abdominal wall in this TAP to reach the rectus
abdominis muscle which they pierce to supply the skin in front of the abdomen.
The intercostal, subcostal, iliohypogastric and ilioinguinal nerves course
through the lateral abdominal wall within the TAP before piercing the muscle to
innervate the abdominal wall, upper anterior part of the gluteal region and
upper and medial part of the thigh and part of the skin covering the genitalia
[3-6].
TAP block, as described by Mukthar [6], provides anesthesia to parietal
peritoneum as well as skin and muscles of anterior abdominal wall by blocking
these nerves.
In 1993, Kuppuvelumani et al. [7] injected local anesthetic (0.5%
Bupivacaine 20 ml on each side) into a point just above the iliac crest,
bilaterally and found it to be useful as a technique for postoperative pain
management in patients undergoing caesarean section. Rafi [8] formally
described and portrayed it as a new abdominal field blocks with a targeted
single shot local anesthetic delivery into the TAP. Since then it has undergone
several modifications. McDonnell et al. [9] adopted the term TAP block in
2007and demonstrated its utility for postoperative pain management in patients
undergoing lower abdominal surgeries.
The drug injected into the TAP spreads from the superior margin of the
iliac crest to the level of the costal margin and posteriorly up to the
quadratus lumborum muscle [10-16].
TAP block is given using either conventional landmark technique or using
Ultra Sound Guidance.
In the landmark technique, TAP is accessed as described by
In the USG technique, USG is
used to insert the needle in plane and inject the drug into TAP [17,18].
The landmark technique is simple
and easy to perform while USG technique can improve accuracy and reduce
complications. The success rate has been claimed to be 85% in experienced
hands. TAP block is increasingly becoming popular because of its simplicity in
performing and also its effectiveness.
Duration of post-operative
analgesia (time interval between TAP block given and the time to first dose of
analgesic requested by the patient), Patient’s acceptability and satisfaction,
post-operative opioid/other analgesics (ketamine, NSAIDs, alpha 2 agonists and
paracetamol) consumed in the first 24-48 h, complications such as block
failure, bleeding, wound infection, respiratory depression, local anesthetic
toxicity, nausea and vomiting requiring treatment are noted as monitored
parameters. Pain scores (VAS) were assessed at 2, 4, 6, 12, 24, 36 h post-operatively.
Laffey and McDonnell [19] in
their study found that the upward spread of local anesthetic in the TAP takes
longer time and estimation of upper level of the block before the spread of the
drug is inaccurate.
Aveline et al. [20] in their
randomized control study, compared TAP block and ilioinguinal/iliohypogastric
nerve block for inguinal hernia repair on 273 patients as a day care procedure
and found that USG TAP block provided better post-operative analgesia and
reduced opioid demand than blind IHN/IIN block. Patients who received a TAP
block experienced less pain at rest on VAS scale at 4, 12 and 24 h
post-operatively.
Their study included enough
patients (134 in TAP block and 139 in IHN/IIN block) to obtain some definitive
information about the complications and quality and duration of analgesia. The
results of their study was in accordance with the study conducted by various
scientists, who concluded that TAP block provided effective analgesia during
first 24 h after lower abdominal surgeries.
Many other studies who have used
landmark technique for TAP block have shown that TAP block provides effective
post-operative analgesia in the first 24-48 h with reduced (>70%) dose of
opioid and other analgesic requirement in the first 24 h with reduced incidences
of post-operative complications [8-14].
Individual studies by Mishra et
al. [21] and meta-analysis and reviews of clinical studies by many other
authors revealed that TAP block is an excellent mode of post-operative pain
management, especially in lower abdominal surgeries and in patients with
multiple co-morbidities.
Some studies have reported using
USG placement of an epidural catheter in the TAP for continuous TAP block.
Resistance to catheter insertion can be reduced by injecting 5-10 ml of saline
into the TAP beforehand [17].
Many of the anesthetists have
used different drugs like, 0.5% bupivacaine, 0.5% L-bupivacaine, 1.5%
mepivacaine, 0.75% ropivacaine in their separate studies and found that TAP
block can be used as an alternative technique for post-operative pain
management in patients undergoing lower abdominal surgeries, especially in
patients with multiple co-morbidities, and found that USG TAP block gives
better results than blind technique [19,22-24].
The onset and duration of
analgesia varied with the concentration and volume of the drug used and also
the pharmacodynamics of the drug used.
In our studies, conducted in
Rajarajeswari Medical College, Bengaluru, India, we have followed blind
landmark technique as described by McDonnell et al. [2,4] in 2007, in
anesthetizing 60 patients undergoing unilateral inguinal hernia repair as sole
anesthesia technique and also in another study, estimating the efficacy of
bilateral TAP block for post-operative analgesia in 60 patients undergoing
elective Caesarean deliveries using 0.5% bupivacaine in 30 patients and 0.75%
ropivacaine in another 30 patients. We have found that TAP block can be used as
a sole anesthetic technique for inguinal hernia repair. It also gives excellent
post-operative analgesia in patients undergoing elective Caesarean delivery.
The onset and duration of analgesia varied with the drug used and the
concentration at which it is used.
CONCLUSION
As with the conclusion of the
previous authors studies and conclusion, along with the results of our study,
it can be concluded that TAP block given either by landmark technique or USG
technique, USG catheter for continuous TAP block or sub-costal USG TAP block,
is an excellent alternative anesthetic technique in patients undergoing
inguinal hernia repair and an excellent alternative postoperative analgesic
technique in patients undergoing caesarean delivery, total abdominal
hysterectomy, radical prostatectomy, appendectomy with least postoperative
complications.
Though many other techniques like
paravertebral block, quadratus lumborum block, erectar spinae block, rectus
sheath block, inguinal field block have been introduced for postoperative
analgesia in patients undergoing lower abdominal surgeries and claim that
quadratus lumborum block and erectar spinae block are excellent modes of
providing postoperative analgesia in patients undergoing lower abdominal
surgeries, TAP block performed using US guidance by an experienced anesthetist
still has its role as a postoperative technique in such patients.
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