The combination of transversus abdominis plane block and rectus sheath block reduced postoperative pain after splenectomy: a randomized trial

Rectus Sheath and Transversus Abdominis Plane Blocks for Preaponeurotic Endoscopic Repair: Is the Double Block the Solution for Postoperative Pain Management?

BACKGROUND

Diastasis recti abdominis (DRA) is a prevalent postpartum condition characterized by the separation of the rectus abdominis muscles with an interrectal distance >2.5 cm, often leading to symptoms like back pain, constipation, and urinary incontinence. Preaponeurotic endoscopic repair (REPA) is a novel, minimally invasive surgical approach for DRA, offering an alternative to traditional abdominoplasty. Despite its minimally invasive nature, REPA surgery poses significant postoperative pain challenges, typically managed with opioids, which carry numerous side effects.

MATERIALS AND METHODS

This retrospective study evaluates the efficacy of combining 2 ultrasound-guided abdominal wall blocks, rectus sheath block (RSB) and transversus abdominis plane block (TAPB), to manage postoperative pain in 55 DRA patients who underwent REPA surgery. We performed lateral TAPB in 28 cases, whereas 27 received an association of TAPB and RSB.

RESULTS

At 6 hours postsurgery, 61% of patients in the TAPB group reported significant pain (Numeric Rating Scale >3), compared with 19% in the TAPB-RSB group (P = 0.001). The TAPB-RSB group also required fewer analgesic rescue doses (P = 0.042) and showed earlier recovery, with faster initiation of oral intake and mobility.

CONCLUSION

The combination of TAPB and RSB significantly reduces opioid consumption, postoperative pain, and the need for rescue analgesia compared with TAPB alone. The dual-block approach, providing a multi-dermatomal sensory block, suggests a promising strategy for improving postoperative pain management in REPA surgery.

Comparison of the effectiveness of subcostal transversus abdominis plane and rectus sheath blocks in postoperative analgesia in major open gynecological cancer surgeries: a prospective randomized study

BACKGROUND

The transversus abdominis plane block (TAPB) is frequently used for postoperative analgesia in abdominal surgery. However, it remains insufficient for analgesia during upper abdominal surgeries. Therefore, we compared the efficacy of the subcostal transversus abdominis plane block (STAPB) or rectus sheath block (RSB), in addition to the posterior transversus abdominis plane block (PTAPB), for postoperative analgesia in major gynecologic cancer surgeries.

METHODS

This prospective randomized study included 50 patients aged > 18 years (American Society of Anesthesiologists physical status II or III), who underwent gynecologic cancer surgery through a midline incision. All patients underwent PTAPB, STAPB, or RSB according to the randomization. The following parameters were recorded and compared: demographic data; intraoperative hemodynamic parameters; numeric rating scale (NRS) pain levels at the 1st, 6th, 12th, and 24th postoperative hours; opioid consumption; number of requests and boluses; adverse effects; surgical complications within 24 h.

RESULTS

Forty-seven patients were included in this study. In the STAPB group, postoperative 1, 12 and 24 h NRS values were lower; opioid consumption, opioid demand, and bolus numbers were lower during the postoperative 24 h as compared to RSB (P < 0.05). The intraoperative opioid and hemodynamic values were similar in both groups.

CONCLUSIONS

STAPB in addition to PTAPB provides more effective analgesia than RSB for postoperative pain management in open gynecologic cancer surgeries.

Effect of Rectus Sheath Block on Postoperative Quality of Recovery After Transabdominal Midline Gynecological Surgery: A Randomized Controlled Trial

Introduction

Rectus sheath block is an emerging technique that provide effective perioperative analgesia and is related to lower perioperative opioid consumption and decrease opioid-related adverse effects. The present research is designed to explore the effect of rectus sheath block on recovery quality in patients following transabdominal midline gynecological surgery.

Methods

Ninety female patients following elective transabdominal midline gynecological surgery were enrolled. Patients were randomized to group R (n = 45) which receive preoperative ultrasound-guided RSB with 0.4% ropivacaine or group C which is control group (n = 45). The primary outcome was the quality of recovery on the first postoperative day. The quality of recovery was assessed by the 40-item Quality of Recovery questionnaire (QoR-40). Secondary outcomes included the intraoperative opioid consumption, time to first flatus and time to first discharging from bed, postoperative nausea and vomiting, and patient satisfaction.

Results

The patients in two groups had comparable baseline characteristics. Postoperative global QoR-40 scores were significantly better in group R than in group C (165.0[159.5-170.0] vs 155.0[150.0-157.0], respectively; median difference 12[95% confidence interval: 8-15, P<0.001]). Preoperative RSB reduced intraoperative opioid consumption, reduced the time to first flatus, time to first discharging from bed and the post anaesthesia care unit discharge time. Furthermore, group R showed greater patient satisfaction.

Conclusion

A single preoperative administration of RSB with ropivacaine improved the quality of recovery in patients following transabdominal midline gynecological surgery.

Preoperative versus postoperative ultrasound-guided rectus sheath block for acute postoperative pain relief after laparoscopy: A retrospective cohort study

Although rectus sheath block (RSB) is routinely used in laparoscopic surgeries to reduce mid-abdominal pain, whether RSB should be performed before or after surgery remains unclear. Herein, the optimal timing for RSB in patients undergoing laparoscopic surgery was investigated. This retrospective cohort study analyzed the data of patients who underwent RSB during laparoscopic procedures at our hospital between January 2013 and December 2018. The primary outcome was the time to rescue analgesia within 24 hours postanesthesia. The patients were divided into preoperative (pre-) and postoperative (post-) RSB groups. A multivariable Cox proportional hazards regression model was used to analyze the time to rescue analgesia in the unmatched and propensity score (PS)-matched patient populations. In total, 609/14,284 patients were included (pre-RSB group, 227 patients; post-RSB group, 382 patients). After PS matching, 97 patients were assigned to both groups. Although the time from extubation to the first analgesic request was not significantly different between the 2 groups (322 vs 294 minutes, P = .57), the patients in the pre-RSB group showed a lower risk of postoperative first analgesic administration after PS matching (adjusted hazard ratio, 0.71; 95% confidence interval, 0.53-0.95; P = .023). Among patients undergoing laparoscopic surgery, those in the pre-RSB group tended to have a longer time to the first analgesic request and had a lower risk of analgesic administration within the first 24 hours than those in the post-RSB group. Thus, performing RSB preoperatively may be preferable.

Combined rectus sheath block with transverse abdominis plane block by one puncture for analgesia after laparoscopic upper abdominal surgery: a randomized controlled prospective study

BACKGROUND

Rectus sheath block (RSB) and transversus abdominis plane block (TAPB) have been shown to reduce opioid consumption and decrease postoperative pain scores in abdominal surgeries. However, there are no reports about the one-puncture technique of RSB combined with TAPB for perioperative pain management during laparoscopic upper abdominal surgery.

METHODS

A total of 58 patients were randomly assigned to the control group (C), the TAP group (T), and the one-puncture technique of RSB combined with TAPB group (RT). The patients in group C did not receive any regional block. The patients in group T received ultrasound-guided subcostal TAPB with 30 mL of 0.33% ropivacaine on each side. The patients in the RT group received a combination of RSB and TAPB with 15 mL of 0.33% ropivacaine in each plane by one puncture technique. All patients received postoperative patient-controlled intravenous analgesia (PCIA) after surgeries. The range of blocks was recorded 20 min after the completion of the regional block. The postoperative opioid consumption, pain scores, and recovery data were recorded, including the incidence of emergence agitation (EA), the times of first exhaust and off-bed activity, the incidence of postoperative nausea and vomiting, dizziness.

RESULTS

The range of the one-puncture technique in group RT covered all areas of surgical incisions. The visual analogue scale (VAS) score of the RT group is significantly lower at rest and during coughing compared to groups T and C at 4, 8, 12, and 24 h after surgery, respectively (P < 0.05). The consumption of sufentanil and the number of postoperative compressions of the analgesic pumps at 24 and 48 h in the RT group are significantly lower than those in groups T and C (P < 0.05). The incidence of EA in the RT group is significantly lower than that in groups T and C (P < 0.05).

CONCLUSION

The one-puncture technique of RSB combined with TAPB provides effective postoperative analgesia for laparoscopic upper abdominal surgery, reduces the incidence of EA during PACU, and promotes early recovery.

TRIAL REGISTRATION

ChiCTR, ChiCTR2300067271. Registered 3 Jan 2023, http://www.chictr.org.cn .

Rectus Sheath Block Improves Patient Recovery Following Open Aortic Surgery

BACKGROUND

Postoperative pain management remains a barrier to recovery following aortic surgery. Although epidural catheters help in adjunctive pain management, less is known about the use of rectus sheath blocks. We compared patient recovery following open abdominal aortic surgery (OAS) with and without adjunctive rectus block.

METHODS

Adult patients undergoing open abdominal aortic aneurysm repair and aortobifemoral or aortoiliac bypass for occlusive disease were identified and stratified by use of general anesthesia alone (GA) versus adjunctive use of a rectus sheath block (GA + RB). A small number of patients with GA and concomitant epidural analgesia, along with patients that had retroperitoneal repairs, were not included in further analysis. Outcomes included time to extubation, intraoperative and postoperative morphine milligram equivalents (MME) utilization, length of stay, discharge MME, and postoperative complications. Categorial data were compared with Person Chi-Square tests or Fisher's exact tests. Continuous data were tested with independent t-tests or Mann-Whitney U-tests.

RESULTS

From January 2017 to April 2022, there were 106 patients who underwent open aortic surgery, 55 patients with GA alone, 39 with GA + RB, and 12 patients who had a GA with concomitant epidural analgesia. Between GA and GA + RB, patients were comparable in both groups in terms of age, BMI (body mass index), smoking history, hypertension, diabetes, CAD (coronary artery disease), COPD (chronic obstructive pulmonary disease), and ASA (American Society of Anesthesiologists) class and prior opioid use. Patients with GA + RB were more likely to have scheduled elective procedures (80% GA cohort vs. 94.9% RB, P = 0.040), and a lower incidence of retroperitoneal exposure (14.5% GA cohort vs. 0% RB, P = 0.019). Patients with GA + RB had shorter time to extubation than GA (84.6% < 12 hr vs. 44.4%, P < 0.001), greater rate of procedural ketamine usage (GA + RB: 61.5% vs. GA: 40.0%, P = 0.049), lower MME at first postoperative day (median MME GA + RB: 25.0 vs. GA: 67.5, P = 0.002), lower discharge MME (median MME GA + RB: 142.5 vs. GA: 225.0, P = 0.036), and overall shorter length of stay (median stay GA + RB: 5 vs. GA: 6 days, P = 0.006). Postoperative complications were similar between groups. Similar findings were found in the comparison between elective-only GA and GA + RB patients and after exclusion of patients who only had a single shot of regional anesthesia.

CONCLUSIONS

Patients that receive adjunctive rectus sheath blocks for pain control following OAS utilize fewer opioid medications during hospital stay and at discharge. Rectus sheath blocks represent an alternative option to other periprocedural analgesia following open aortic surgery.

Can Postoperative Pain Be Prevented in Bariatric Surgery? Efficacy and Usability of Fascial Plane Blocks: a Retrospective Clinical Study

BACKGROUND

Providing analgesia after bariatric surgery might be challenging due to a high prevalence of obstructive sleep apnea syndrome and the increased sensitivity to respiratory depression triggered by opioid overuse after surgery. Various combination methods with paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and other pain medications such as ketamine or gabapentin have been suggested for reduction of the opioid usage. Regional anesthetic techniques represent a valuable option as they improve patient comfort while reducing opioid-related side effects. In this study, we have evaluated the adjuvant benefits of these various techniques in reduction of the postoperative pain in bariatric surgery.

METHODS

After the approval of the IRB Ethics Committee, the records of the patients who had laparoscopic bariatric surgery between January 2019 and December 2021 were reviewed retrospectively.

RESULTS

Records of 120 patients who underwent laparoscopic bariatric surgery between January 2019 and December 2021 were reviewed. In total, 113 patients with full documentation were included in this study. Among these, 74 patients were administered regional analgesia. The main regional analgesia techniques were transversus abdominis plane and rectus sheath block. The pain scores of those receiving regional analgesia were statistically low. The opioid consumption after transversus abdominis plane and rectus sheath block was significantly lower than that of others. External oblique intercostal block alone provides a postoperative opioid consumption similar to those of transversus abdominis plane and rectus sheath block.

CONCLUSION

The use of fascial plane blocks in bariatric surgery significantly reduces opioid consumption. Transversus abdominis plane and rectus sheath block combination and external oblique intercostal block seem to be the most effective options.

CLINICAL TRIALS NUMBER

NCT05284695.

Abdominal wall blocks for emergency ileostomy operation in a patient with COVID-19 pneumonia: a case report

The anesthesia method to be administered during emergency surgical procedures for COVID-19 (Coronavirus Disease 2019) pneumonia patients carries great importance for both patient and surgical team. Regional blocks are generally used to ensure postoperative analgesia after abdominal surgery with general anesthesia. In this case, involving a patient receiving anticoagulant treatment due to COVID-19 pneumonia with planned emergency operation, the aim was to present the anesthesia management with rectus sheath and transversus abdominis plane block combination for the ileostomy operation. Due to the administered blocks, the patient was not given general anesthesia. Hence, transmission was reduced by minimizing aerosol formation in terms of protecting health personnel and worsening of the patient's pneumonia was prevented. The case is discussed in terms of regional anesthesia techniques offering a good alternative in appropriate cases for both employee and patient safety in the present day, when the whole world is affected by the COVID-19 pandemic.