Efficacy of transversus abdominis plane block and rectus sheath block in laparoscopic inguinal hernia surgery

Ultrasound-guided quadratus lumborum block: Posterior versus anterior approach in paediatrics undergoing laparoscopic inguinal hernia repair

Background and Aims

Regional anaesthesia has gained popularity in managing post-operative pain in paediatric patients. Quadratus lumborum block (QLB) is recognised as one of the peri-operative pain management techniques used during abdominal surgeries. However, no consensus about the best approach has been reached.

Material and Methods

Sixty paediatric patients with ages ranging from 1 to 6 as well as classification I and II of the American Society of Anesthesiologists, scheduled for laparoscopic inguinal hernia, were allocated to receive either a posterior approach (Group I) or an anterior approach (Group II) QLB. Twenty four-hour morphine consumption, the face, legs, activity, cry, and consolability (FLACC) score, duration of analgesia, performance time, and block-related complications were recorded.

Results

Group II showed significantly lower morphine consumption as well as a longer duration of analgesia (P = 0.039*, 0.020*, respectively), with an equivalent period for block performance being reported in the two groups (P = 0.080). At 2, 4, 6, and 12 hours post-operatively, the FLACC scores were substantially diminished in Group II compared to Group I (P = 0.001*, 0.012*, 0.002*, 0.028*, respectively). However, at twenty-four hours, comparable pain scores were observed between both groups (P = 0.626). In addition, there were no block-related complications.

Conclusions

In paediatric patients scheduled for laparoscopic inguinal hernia repair, the ultra-sound-guided anterior approach of the QLB was associated with significantly reduced post-operative morphine consumption, a lower FLACC score, and a longer analgesia duration when compared to the posterior approach.

Pre-peritoneal Plus Portal Infiltration Versus Bilateral Transversus Abdominis Plane Block in Laparoscopic Hernia Repair

Background and objective The role of the pre-peritoneal infiltration of local anesthetic (PILA) in laparoscopic hernia repair has been equivocal. Ultrasound-guided transversus abdominis plane (TAP) block has been extensively studied. However, studies comparing these two methods are very scarce. Hence, this study was undertaken to compare the efficacy of pre-peritoneal plus portal infiltration with TAP block in this population. Materials and methods This double-blinded randomized comparative study was conducted on a total of 32 patients by allotting 16 patients in each group. Group A patients were given pre-peritoneal plus portal infiltration of 15 mL of 0.5% ropivacaine for each technique by the operating surgeon, while Group B patients were administered bilateral TAP block with 0.5% ropivacaine, 15 mL on each side under ultrasound guidance by the anesthesiologist. Results The demographic variables and duration of surgery were comparable between the two groups. Also, the postoperative requirement of fentanyl between the two groups was insignificant. However, the duration of anesthesia was significantly longer in Group B attributing to the extra time taken for the administration of the TAP blocks. Conclusion Both ultrasound-guided TAP block and the PILA plus portal infiltration are effective techniques for pain relief after laparoscopic hernia repair. Either of these two techniques can be chosen depending on the availability of resources, expertise, etc.

Transversus abdominis plane blocks in laparoscopic inguinal hernia repair: a review

INTRODUCTION

Throughout its history, there have been significant advances in pain control of inguinal hernia repairs. One of the most recent developments is locoregional pain blocks. There is a multitude of literature available on laparoscopic inguinal hernia repair and transversus abdominis plane (TAP) blocks.

OBJECTIVES

This paper seeks to provide a thorough and systematic literature review on the role of TAP blocks in laparoscopic inguinal hernia repairs.

METHODS

PubMed and Google Scholar were searched for relevant literature using predetermined medical subject heading (MeSH) terms: "(TAP block)" AND "(Laparoscopic inguinal hernia repair)".

RESULTS

A total of 166 publications were identified, from which 18 publications were included in the final review after eligibility criteria were applied.

CONCLUSION

The majority of studies conclude that TAP blocks performed in the setting of laparoscopic inguinal hernia repair improve post-operative pain and mobility, decrease opiate analgesic usage, and are superior in pain control compared to other modalities of regional anesthesia. Thus, to improve post-operative outcomes and patient satisfaction, TAP blocks should be heavily considered for routine use in surgical practice for laparoscopic inguinal hernia repair.

Risk factors predicting acute postoperative pain immediately after minimally invasive inguinal hernia repair

Introduction

Acute postoperative pain remains one of the most common problems, even after laparoscopic or endoscopic hernia repair. Avoiding predictive factors for acute pain after surgery or prescribing additional analgesia for a patient who has risk factors that cannot be removed can be one of the options to reduce acute postoperative pain. However, there is a lack of clinical studies that evaluate the predictive factors of postoperative pain after transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) surgeries.

Aim

To identify independent risk factors predicting pain after laparoscopic and endoscopic inguinal hernia repair.

Material and methods

A prospective, randomized clinical trial was carried out by randomising patients into 2 groups (TAPP and TEP). Pre-operative and peri-operative findings were recorded. Postoperative pain was evaluated 3 h after the surgery using a visual analogue scale (VAS). Groups of patients who felt mild pain (VAS 0-2) and patients who felt average or severe pain (VAS 3-10) were compared.

Results

A total of 132 male patients were included in the study. Disease duration of more than 1 year, smoking, and TAPP surgery significantly increase the risk of moderate and strong pain 3 h after surgery. Conversely, shorter duration of symptoms and physical occupation decrease the risk of acute pain score greater than 3 according to the VAS.

Conclusions

The study shows that the duration since groin hernia appearance, smoking, physical occupation, and TAPP technique are possible predictive factors for acute postoperative pain after minimally invasive inguinal hernia repair. We suggest that for patients who have those predictors, some factors can be avoided or additional analgesia can be used.

Abdominal Wall Block Decreases Intraoperative Opioid Con-Sumption by Surgical Pleth Index-Guided Remifentanil Administration in Single-Port Laparoscopic Herniorrhaphy: A Prospective Randomized Controlled Trial

Abdominal wall blocks (AWBs) can reduce pain during surgery and lessen opioid demand. Since it is difficult to know the exact level of intraoperative pain, it is not known how much the opioid dose should be reduced. In this study, using the surgical pleth index (SPI), which indicates pain index from sympathetic fibers, the amount of remifentanil consumption was investigated. We conducted single-port laparoscopic hernia repair in 64 patients, as follows: the regional block group (R group) was treated with AWB, while the control group (C group) was only subjected to general anesthesia. In both groups, the remifentanil concentration was adjusted to maintain the SPI score between 30 and 40 during surgery. The primary parameter was the amount of remifentanil. A total of 52 patients completed the study (24 in the R group, 28 in the C group). The remifentanil dose during surgery was decreased in the R group (29 ± 21 vs. 56 ± 36 ng/kg/min; p = 0.002). Visual analogue scale score and additional administrated analgesics were also low in the R group. As such, AWB can reduce the remifentanil dose while maintaining the same pain level.

Utility of the transversus abdominis plane and rectus sheath blocks in patients undergoing anterior lumbar interbody fusions

BACKGROUND CONTEXT

Anterior lumbar interbody fusion (ALIF) is a well-established technique to address numerous pathological conditions of the spine and to restore sagittal spine balance. Improving patient comfort and reducing opioid consumption following lumbar fusions is a significant goal for spine surgeons. Therefore, there is a growing need to explore multimodal options for pain management post-surgery.

PURPOSE

Determine the effectiveness of combined transversus abdominis plane (TAP) and rectus sheath (RS) blocks in those undergoing (ALIF) as compared to a historical control.

STUDY DESIGN/SETTING

Retrospective comparative cohort performed at a tertiary referral orthopedic specialty hospital.

PATIENT SAMPLE

Of the 175 patients (88 patients received a combined regional block) who underwent an ALIF between January 1, 2018 and August 1, 2021.

OUTCOME MEASURES

Pain scores both during activity and at rest, opioid consumption during the first 72 hours postoperatively, total postoperative anesthesia care unit length of stay (PACU LOS), 30-day emergency department visits, 30-day readmissions, and unplanned returns to the operating room.

METHODS

Charts of patients undergoing an ALIF during the open period for this study were placed into two groups: those that received combined regional anesthesia and those that did not. A t test assuming unequal variances was used to determine if there were differences in outcome variables between the two groups.

RESULTS

The study group, those receiving the combine block, demonstrated a statistically significant reduction in opioid pain medicine (24.8%), reported pain (10-13%), and PACU LOS (18.7%). There were no differences in complication rates between the two groups.

CONCLUSIONS

The combined use of TAP and RS blocks appears to be a well-tolerated and effective means of pain management in this patient cohort.

Effect of perineural bupivacaine infiltration on reducing inguinodynia in patients undergoing inguinal meshplasty - a randomized controlled trial

INTRODUCTION

Inguinodynia after inguinal meshplasty is a notable complication with an incidence of 13-37%. We wanted to determine if a perineural infiltration of bupivacaine given intraoperatively would reduce the incidence of immediate postoperative pain and inguinodynia.

METHODOLOGY

We have conducted a single-blinded randomized controlled trial including 100 patients with inguinal hernia. Patients in the control group received only spinal anaesthesia. The intervention group received perineural bupivacaine infiltration in addition to spinal anaesthesia. Intraoperatively Ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerve was identified and 2 mL of 0.5% bupivacaine was given perineurally along these identified nerves. Presence of inguinodynia, immediate post-operative pain scores using the Wong-Baker faces pain scale, duration of analgesics use, use of additional analgesics along with Paracetamol 500 mg tablet, and the length of hospital stay between the groups were recorded.

RESULTS

100 patients were randomized in the study, 49 in control and 51 in the intervention group. Both the group was comparable in terms of demographic characteristics. The intervention group had significantly lower median pain score at 3 h [4 ± 1.662 vs. 6 ± 1.55; p = .0001] and 6 h [4 ± 1.33 vs. 6 ± 1.307; p = .0001]. The incidence of inguinodynia did not significantly differ between the two groups (p-value = .12).

CONCLUSION

Intraoperative Perineural bupivacaine infiltration significantly reduces the immediate postoperative pain. However, there was no significant reduction in the incidence of inguinodynia or additional analgesic requirement.

The Effect of Intraoperative Transversus Abdominis Plane Blocking on Postoperative Pain After Laparoscopic Transabdominal Pre-peritoneal (TAPP) Groin Hernia Repair

Background

Managing postoperative pain even after laparoscopic groin hernia repair still remains an interesting challenge for clinicians especially for patients of high risk. Plenty of operative techniques and analgesic methods have been proposed in order to minimize postoperative pain after laparoscopic groin hernia repair. The aim of the present study is to compare transverse abdominis plane (TAP)-block with local analgesic infiltration at trocar entry sites in the terms of reducing postoperative pain.

Methods

Patients that underwent laparoscopic trans-abdominal pre-peritoneal (TAPP) groin hernia repair in a high-volume university hospital were included. Patients were divided in two groups depending on the analgesic method used. Pain was assessed using Visual Numerical Scale (VNS) score.

Results

Thirty patients were included. Intraoperative TAP-block seemed to be superior in terms of decreasing pain at the hernia area and at the trocar insertion site (p < 0.05) compared to local analgesic infiltration at the trocar insertion site at 6, 12 and 24 h after surgery (p < 0.05). In addition, pain reduction was more effective in rest rather than in motion for both analgesic methods.

Conclusion

Intraoperative TAP-block under direct vision seems to be an effective, fast and easy technique in order to reduce postoperative pain after laparoscopic groin hernia repair, but more studies are required to validate these results in a prospective and randomized context.

Effect of implementing enhanced recovery after surgery principles in the perioperative period of pediatric inguinal hernia

OBJECTIVE

We aimed to investigate the effect of implementing enhanced recovery after surgery (ERAS) principles in the perioperative period of pediatric inguinal hernia (IH).

METHODS

In this prospective study, 98 children undergoing surgery for IH in our hospital were randomly divided into the control group (n=49, routine nursing) and the study group (n=49, nursing care with ERAS principles). The anesthesia recovery period, time from end of surgery to first ambulation and to first anal exhaust, length of hospital stay, mental state before and after the intervention, pain level, incidence of complications, and family satisfaction with the nursing care were compared between the two groups. The recurrence rate of IH within half a year was recorded.

RESULTS

Compared with the control group, the time from the end of surgery to first ambulation and to first anal exhaust and the length of hospital stay were shorter in the study group (all P<0.05). After the nursing intervention, both groups achieved better scores in mental state and pain level, and the improvement in the study group in mental state and pain level was greater than that in the control group (all P<0.05). Compared with the control group, the study group had higher family satisfaction with the nursing care and lower incidence of complications during hospitalization (both P<0.05). During the half-year follow-up, no recurrence was observed in both groups.

CONCLUSION

The implementation of ERAS principles in the perioperative period of pediatric IH can help to relieve postoperative pain, reduce psychological discomfort, reduce the incidence of complications, and promote postoperative recovery in children.

Randomised, double-blinded, placebo-controlled trial to investigate the role of laparoscopic transversus abdominis plane block in gastric bypass surgery: a study protocol

INTRODUCTION

Evaluating the efficacy of a laparoscopically guided, surgical transversus abdominis plane (TAP) and rectus sheath (RS) block in reducing analgesic consumption while improving functional outcomes in patients undergoing laparoscopic bariatric surgery.

METHODS

150 patients Living with obesity undergoing elective laparoscopic Roux-En-Y gastric bypass for obesity will be recruited to this double-blinded, placebo-controlled randomised controlled trial from a Bariatric Centre of Excellence over a period of 6 months. Patients will be electronically randomised on a 1:1 basis to either an intervention or placebo group. Those on the intervention arm will receive a total of 60 mL 0.25% ropivacaine, divided into four injections: two for TAP and two for RS block under laparoscopic visualisation. The placebo arm will receive normal saline in the same manner. A standardised surgical and anaesthetic protocol will be followed, with care in adherence to the Enhanced Recovery after Bariatric Surgery guidelines.

ANALYSIS

Demographic information and relevant medical history will be collected from the 150 patients enrolled in the study. Our primary efficacy endpoint is cumulative postoperative narcotic use. Secondary outcomes are peak expiratory flow, postoperative pain score and the 6 min walk test. Quality of recovery (QoR) will be assessed using a validated questionnaire (QoR-40). Statistical analysis will be conducted to assess differences within and between the two groups. The repeated measures will be analysed by a mixed modelling approach and results reported through publication.

ETHICS AND DISSEMINATION

Ethics approval was obtained (20170749-01H) through our institutional research ethics board (Ottawa Health Science Network Research Ethics Board) and the study results, regardless of the outcome, will be reported in a manuscript submitted for a medical/surgical journal.

TRIAL REGISTRATION NUMBER

Pre-results NCT03367728.

The transversus abdominis plane block may reduce chronic postoperative pain one year after TAPP ingunial hernia repair

Introduction

Chronic postoperative inguinal pain (CPIP) is defined as pain impacting daily activities lasting at least 3 months. With an incidence of 0.5–6.0%, chronic pain affects many patients who underwent inguinal hernia repair (IHR). Early severe postoperative pain has been described as a risk factor for CPIP. Thus, we aim to investigate the impact of the transversus abdominis plane (TAP) block on CPIP.

Methods

From 2013 to 2019 we collected data from individuals who were operated on electively in TAPP technique and who received a preoperative TAP block.

Results

Data from 289 patients were selected. 259 patients were male. The mean age was 59.93 years and the mean BMI was 25.72 kg/m2. 252 patients suffered from a primary inguinal hernia. No mesh fixation was conducted. 21 patients reported pain at rest, 26 pain under physical exertion and 13 patients required treatment of their pain. In 6.25% of cases patients reported CPIP. We compared our findings with data from the German Herniamed Registry (unilateral, primary IH, men, no mesh fixation; n = 8.799), because we assume that the majority of these patients did not receive a TAP block. The rate of pain under physical exertion (9.2% vs. 10.05%) and pain requiring treatment (2.45% vs. 2.95%) one year after surgery slightly differs without a statistical significance.

Conclusions

We assume that the TAP block may reduce CPIP, postoperative pain during physical exertion and pain requiring treatment following IHR in TAPP technique. Additional randomized clinical trials are mandatory to evaluate the hypothesis.

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The TAP block may reduce the rate of chronic postoperative inguinal pain.

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The TAP block may reduce the rate of pain requiring treatment and on exertion one year after IHR.

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The TAP should further implemented into daily hernia surgery routine.

The transversus abdominis plane block reduces the cumulative need of analgesic medication following inguinal hernia repair in TAPP technique: a retrospective single center analysis among 838 patients

PURPOSE

Laparoscopic inguinal hernia repair (IHR) may lead to early postoperative pain. Therefore, opioid and non-opioid analgesic agents are often administered in the post-anesthesia care unit (PACU). To reduce the postoperative cumulative need of analgesic medication, as well as to accelerate the physical recovery time, the transversus abdominis plane (TAP) block has recently been studied. The TAP block is a regional anesthesia technique. Even though there is evidence about the efficacy of the block used in procedure such as an open inguinal hernia repair, the evidence regarding its use for the TAPP (transabdominal preperitoneal) technique remains low. We aim to provide more sufficient evidence regarding this topic.

METHODS

A monocentric retrospective observational study investigating the effect of the TAP block prior to primary IHR in TAPP technique was conducted. The data of 838 patients who were operated on using this technique from June 2007 to February 2019 were observed. 72 patients were excluded because of insufficient information regarding their analgesic medication protocol. The patients' data were taken from their files.

RESULTS

The patients in the TAP block group (n = 364) did not differ statistically significantly compared to the control group (n = 402) in terms of gender, BMI and age. Individuals of the TAP block group experienced less postoperative pain in the PACU (p < 0.001) and received less analgesic medication (morphine, oxycodone, piritramide, acetaminophen; p < 0.001).

CONCLUSION

We assume that the TAP block is a sufficient approach to reduce postoperative pain and analgesic medication administration for IHR in TAPP technique.

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

Background

Splenectomy performed with a curved incision results in severe postoperative pain. The aim of this study was to evaluate the effect of transversus abdominis plane block and rectus sheath block on postoperative pain relief and recovery.

Methods

A total of 150 patients were randomized into the control (C), levobupivacaine (L) and levobupivacaine/morphine (LM) groups. The patients in the C group received only patient-controlled analgesia. The patients in the L and LM groups received transversus abdominis plane block and rectus sheath block with levobupivacaine or levobupivacaine plus morphine. The intraoperative opioid consumption; postoperative pain score; time to first analgesic use; postoperative recovery data, including the times of first exhaust, defecation, oral intake and off-bed activity; the incidence of postoperative nausea and vomiting and antiemetics use; and the satisfaction score were recorded.

Results

Transversus abdominis plane block and rectus sheath block reduced intraoperative opioid consumption. The patients in the LM group showed lower postoperative pain scores, opioid consumption, postoperative nausea and vomiting incidence and antiemetic use and presented shorter recovery times and higher satisfaction scores.

Conclusions

The combination of transversus abdominis plane block and rectus sheath block with levobupivacaine and morphine can improve postoperative pain relief, reduce the consumption of analgesics, and partly accelerate postoperative recovery.

Trial registration

Chinese Clinical Trial Registry, ChiCTR 1,800,015,141, 10 March 2018.

Predictive factors of post-laparoscopic inguinal hernia acute and chronic pain: prospective follow-up of 807 patients from a single experienced surgeon

INTRODUCTION

Convalescence after hernia repair is one of the main focuses for hernia surgeons. We analyzed our prospectively collected data to identify possible predictive factors for post-operative acute and chronic pain.

MATERIALS AND METHODS

We prospectively collected the demographic data and peri-operative findings. Post-operative acute pain was evaluated with Visual Analog Pain Scale. The chronic pain (pain persists for > 6 months since operation) was also recorded.

RESULTS

From June 2008 to August 2018, there were 807 patients with 1029 sites of inguinal hernia enrolled in our analysis. Pain before operation was associated with the severity of acute pain on OP (operation) day, POD 1 (post-operative day 1), and POD 7 (post-operative day 7). Younger patients had significantly higher post-operative acute pain on OP day, POD 1, and POD 7. The staple mesh fixation method resulted in a higher pain score at OP day and POD 1. The predictive factors for chronic pain were sex (female), young age (< 65 years), having no past history of hypertension, pain before operation, and mesh material.

CONCLUSION

A younger age and inguinal pain before operation were the main predictive factors for higher post-operative pain. Younger patients, females, having inguinal pain before surgery, and using heavy weight mesh have a higher risk of chronic pain.

Pain management in abdominal surgery

BACKGROUND

Abdominal surgery has undergone major changes during the last two decades with a general shift from open, invasive surgery to closed minimally invasive surgery. Accordingly, pain management strategies have also changed, especially with the introduction of ultrasound-guided abdominal wall blocks. Despite laparoscopic abdominal surgery classified as minimal, pain can be quite significant and needs to be addressed appropriately.

PURPOSE

This narrative review focuses on adequate pain strategies for various types of surgery. The respective techniques are described and examples of specific pain management strategies given. Advantages and disadvantages of techniques are discussed. This review can serve as a sort of empirical guideline and orientation for the reader to develop their own strategy as well as bringing surgeons up-to-date with the latest anesthetic techniques.

CONCLUSION

Pain is not less or less relevant in minimally invasive surgery. New hallmarks of a multimodal pain strategy are abdominal wall blocks, either as single shot or continuously. Minor open surgery is best performed under a combination of loco-regional blocks and continuous sedation. Abdominal wall blocks, NSAIDs, and short-acting opioids given by nurses or as PCA present the best multimodal pain strategy in abdominal surgery. Epidural analgesia and spinal anesthesia have become second-line options or are reserved for specific patient morbidities or surgical requirements.

Laparoscopic-assisted transversus abdominis plane block as an effective analgesic in total extraperitoneal inguinal hernia repair: a double-blind, randomized controlled trial

Purpose

Laparoscopic inguinal hernia repair has facilitated early mobilization. Management of post-operative pain is paramount in these day case procedures. The aim of this study was to compare laparoscopic-assisted transversus abdominis plane (TAP) block with periportal local anaesthetic infiltration in managing post-operative pain.

Methods

A double-blind, randomized controlled trial was conducted with patients undergoing elective laparoscopic inguinal hernia repair (January 2016–October 2017). The intervention group received laparoscopic-assisted TAP block with 30 ml 0.25% Bupivacaine. The control group received 15ml of 0.5% Bupivacaine at the periportal sites. Primary outcome measure was assessment of post-operative pain scores using numerical rating on visual analogue scale (VAS) at rest and on coughing at 3 h. Efficacy of TAP block was assessed as reduction in mean pain scores in the order of 2 points using the VAS.

Results

60 (57 males and 3 females) were enrolled; 30 patients were randomized to each group. Patient demographics, anaesthetic and surgical times were similar in both groups. Mean pain scores were significantly reduced in the intervention group at 3 (3.1 vs 1.1 p < 0.001) and 6 h (4.1 vs 1.7 p < 0.001) at rest and on coughing at 3 (4.8 vs 2.1 p < 0.001) and 6 h (5.4 vs 3.0 p < 0.001). Patient satisfaction was higher (8.0 vs 6.8 p < 0.001) and rescue analgesic requirements (169.4vs 71.3 p < 0.001) lower in the intervention group.

Conclusions

This analysis has demonstrated the therapeutic benefit of laparoscopic-assisted TAP block in initial post-operative pain management for patients undergoing elective laparoscopic inguinal hernia repair.