Journal of Anaesthesia and Pain, 2022, Volume: 4, No.

1: 18-21 P-ISSN : 2722-3167

https://jap.ub.ac.id E-ISSN : 2722-3205

Case Report

Ultrasound-guided Transversus Abdominis Plane Block for

Postoperative Analgesia in Patient Undergoing Inguinal Hernia Repair
Heri Dwi Purnomo1, Dimas Yuliar Sevanto1
1
Department of Anestesiology and Intensive Therapy, Sebelas Maret University, Dr. Moewardi General Hospital, Surakarta, Indonesia

ABSTRACT

Background: The Transversus Abdominis Plane (TAP) block technique is one method for inhibiting
abdominal pain stimuli by blocking afferent nerves in the abdominal wall via the Petit triangle. TAP
block action is frequently performed as a postoperative procedure, such as in the case of hernia repair.
The goal of using ultrasound in TAP blocks is to distribute the anesthetic agent accurately in the
appropriate neurovascular plane.
Case: A 66-year-old male geriatric patient with an incarcerated right inguinal hernia and a history of
Hypertensive Heart Disease (HHD) was seen. The patient complained of right groin pain that spread
to the right side of the abdomen. Based on the Electrocardiogram (ECG), atrial fibrillation was
identified as slow ventricular response and Left Ventricular Hypertrophy (LVH). Chest X-ray revealed
cardiomegaly with LVH configuration. ASA III E was assigned to the patient. Regional Anesthesia
Subarachnoid Block (RASAB) was used to perform an emergency hernia repair using a regimen of
Bupivacaine heavy 0.5% 7.5 mg with adjuvant Fentanyl 50 g. Bilateral TAP block administration using
Ropivacaine regimen 0.25% of the total volume of 30 ml was given as postoperative analgesia
management. Hemodynamic monitoring, complications and postoperative pain scale were carried
Correspondence: out in the High Care Unit (HCU). Hemodynamically stable, pain scale was 1-2 at 24 hours postoperative
Dimas Yuliar Sevanto* and no complications.
Department of Anestesiology
Conclusion: TAP block is provide an effective and safe anti-pain effect in patients undergoing hernia
and Intensive Therapy, Sebelas
Maret University, Dr. Moewardi repair with geriatric comorbidities and a history of HHD, as well as to prevent cardiovascular
General Hospital, Surakarta, complications and to speed up postoperative patient mobilization.
Indonesiae-mail:
[email protected]
Keywords: TAP block, postoperative pain, hernia repair

Received: December 2022, Revised: January 2022, 3ublished: February 2023

How to cite this article: Purnomo, HD, DY Sevanto. Ultrasound-guided transversus abdominis plane block for postoperative analgesia in patient
undergoing inguinal hernia repair. Journal of Anaesthesia and Pain. 2023:4(1):18-21.doi: 10.21776/ub.jap.2023.004.01.05

INTRODUCTION The use of the TAP block is indicated in all operations in

Surgery in hernia cases is a common procedure. The use the lower abdominal area, such as: appendectomy, hernia repair,
of ilioinguinal nerve blocks can provide a good analgesic effect cesarean section, abdominal hysterectomy, and prostatectomy.
in post-operative patients. However, ilioinguinal nerve blocks are The use of TAP block in laparoscopic surgery is also considered
challenging and have a high failure rate. An alternative technique, effective. Bilateral block administration can be given to surgery
the Transversus Abdominis Plane (TAP) block, is considered with a midline incision or laparoscopic surgery. Attention to the
easier to perform and effective for use as a peripheral block of administration of anesthetic drug doses in the selection of
the abdomen which includes the ilioinguinal, hypogastric, and bilateral injection sites is prohibited from exceeding the safe
lower intercostal nerves (T7-T11).1–3 limit. 1,5,6
The TAP block procedure itself is often performed as a The TAP block is one way to inhibit pain stimulus in the
postoperative procedure, for example in intestinal resection, abdominal region by blocking the afferent nerves in the
appendectomy, retropubic prostatectomy, nephrectomy, hernia abdominal wall through the Petit triangle. The purpose of the
repair, laparoscopic cholecystectomy and caesarean section. The TAP block itself is to provide anesthetic agents in the area
TAP block, as it became known, was performed by searching for between the internal oblique muscles and the transversus
landmarks without the use of tools. Having developed with time, abdominis muscles which target the spinal nerve endings in that
TAP block is performed with the help of ultrasound in order to area, so that all innervation to the skin and muscles covering the
distribute the anesthetic agent more precisely to increase efficacy abdomen and parietal peritoneum is inhibited. Due to its nature
and minimize side effects.1,4 that works to inhibit the spinal nerves, if during surgery in the

Journal of Anaesthesia and Pain. 2023.Vol.4(1):18-21 18

peritoneal cavity, pain due to muscle spasms or inflammation Hematocrit 43, platelet count 256, leukocyte count 7.9,
after surgery (visceral pain) can still be felt by the patient.1,7 Prothrombin Time (PT) 13.9, Activated Partial Thromboplastin
TAP block itself can be divided into two, blind and Time (aPTT) 30, International Normalized Ratio (INR) 0.960,
ultrasound-guided.technique blind, the entry point for the block transient blood glucose 119, serum electrolytes within normal
is the triangle of Petit (which lies between the inferior border of limits. Based on the ECG examination, slow ventricular response
the costal arch and the iliac crest) and is bounded anteriorly by atrial fibrillation, 55 bpm, normal axis and Left Ventricular
the external oblique muscle and posteriorly by the latissimus Hypertrophy (LVH) was found. On chest X-ray examination, there
dorsi muscle. This technique relies on the "double pops" was cardiomegaly CTR of 57% with LVH configuration and left
sensation felt when the injection passes through the external and hemidiaphragm elevation. The patient was assessed as ASA III E.
internal oblique muscles.2,7 Emergency hernia repair was performed with Regional
anesthesia subarachnoid block (RASAB) using a regimen of
Bupivacaine heavy 0.5% 7.5 mg with Fentanyl 50 µg adjuvant. The
patient's hemodynamics were stable during surgery. The
After the operation was completed, postoperative
anesthesia management was carried out with the bilateral TAP
block using the Ropivacaine regimen 0.25%, a total volume of 30
ml (Figure 2) using ultrasound guide. Local anesthetic agent
deposition show in figure 3. After the operation, the patient was
treated in the High Care Unit (HCU) room with the addition of
the parenteral drug Paracetamol 1 gram per 8 hours.
Hemodynamic monitoring, pain score, and postoperative
complications were carried out.
Observation of the patient for the first 4 hours found
pain by measuring the pain scale using the numeric rating scale
(NRS) in patients with a value of 0-1. No complaints of nausea or
vomiting were found and the patient was hemodynamically
stable with a pulse frequency of 60-70 times/minute and blood
pressure of 140/80 mmHg. Follow-up observation examination
Figure 1. Schematic illustration of the transversus abdominis at 24 hours postoperatively obtained a pain scale using the NRS
plane on ultrasound.7 EO: external oblique, IO: internal oblique, obtained in patients with a value of 1-2 with stable
TA: transversus abdominis, LA: local anesthetic hemodynamics. There were no complaints of nausea or vomiting
at 24 hours postoperatively. The patient is able to tilt left and
To perform the TAP block using ultrasound, it is right, and position himself half-sitting. Complaints of shortness
necessary to prepare: (1) an ultrasound with probe high- of breath after surgery were denied.
frequency a probe cover, (3) an antiseptic for skin disinfection, (4)
an ultrasound sterile, (5) a needle (50mm or 80mm size), (6) 20
ml syringe with injection tube, and (7) local anesthetic drug.7,8
Ultrasound use in regional anesthesia progressively
ended up far reaching with the improvement of ultrasonographic
(USG) innovation and expanded picture quality. In this manner,
the utilization of ultrasound in peripheral nerve blocks gives us
various focal points. Nerve blockade with ultrasonography
diminishes complication hazards by coordinated visualization of
the blocked needle and gives significant block success, lower
dose of nearby anesthetic volume, decreased rescue analgesia,
decreased procedural pain, and diminished chance of vascular Figure 2. The process of local anesthetic injection
and pleural puncture.9,10
This study aims to present a case of an inguinal hernia
that was given postoperative analgesia management with
transversus abdominis plane block with ultrasound guidance.
And to find out how the outcomes obtained from the
management strategy.

CASE
A 66-year-old geriatric male patient with recurrent
incarcerated right inguinal hernia and history of Hypertensive
Heart Disease (HHD). In the anamnesis, the patient complained
of pain in the right groin that radiates to the right abdominal
area.
On physical examination, clear airway, adequate
spontaneous breathing, SpO2 98% with room air,
cardiopulmonary examination found no abnormalities, pulse rate
68x/minute, pulse regular, blood pressure 150/97 mmHg. On
laboratory investigations complete blood Hemoglobin 14, Figure 3. Local anesthetic agent deposition (white arrow)

Journal of Anaesthesia and Pain. 2023.Vol.4(1):18-21 19

DISCUSSION postoperatively were stable.technique block ensures that the
Postoperative pain occurs due to trauma to the tissue anesthetic agent administered (as an effort to manage
of the surgical area and inflammation. The process of trauma and postoperative pain) does not enter the systemic circulation, so
inflammation can cause the release of proinflammatory cytokines that effects on hemodynamics can be avoided, especially in
which can stimulate afferent nerve endings in the nociceptive patients with comorbidities related to the cardiovascular system
pathway, resulting in pain impulses traveling to the sensory as in this case.1,7
center resulting in pain perception. Pain perception can manifest Observation of monitoring pain Numeric Rating Scale
as stress and potentially increase morbidity. The use of anesthetic (NRS) at 4 hours to 24 hours postoperatively. In the first 4 hours,
agents to treat postoperative pain can reduce the postoperative the NRS score was 0-1 (scale 10). TAP block to provide an
stress response in patients so that they can provide good and adequate analgesic effect, especially in abdominal region
satisfying outcomes.5,11 TAP block uses the entry point of the operations that manipulate the structures around the parietal
triangle of Petit (which lies between the inferior border of the peritoneum which can induce somatic pain. Administration of
costal arch and the iliac crest) and is bounded anteriorly by the Ropivacaine as a local anesthetic agent can reduce the effects of
external oblique muscle and posteriorly by the latissimus dorsi local pain felt through the mechanism of ion channel inhibition
muscle. This technique has been known since it was first applied along the spinal nerves. Parenteral administration of paracetamol
as one of the management of post-operative analgesia since is useful for reducing the process of pain perception in the central
early 2000, still adhering to the landmarks (which have been nervous system so that it can reduce the effects of pain due to
described previously) even without navigational aids currently visceral pain due to surgery.2,7
used.2,12 This technique relies on the “double pops” sensation felt Utilization of the TAP block in hernia surgery has also
when the injection is passed through two muscles: the external been reported to provide a maximum effect on patients, both
and internal oblique muscles. The aim is to position the from the comfort and safety aspects.7 Reported from a
anesthetic agent between the internal oblique and transversus Randomized Control Trial conducted at the Universidad de
abdominis muscles.4,13 Caldas, Columbia, it was concluded that the intervention group
The use of the TAP block is considered easy and with the TAP block performed postoperatively provided an anti-
effective, suitable for surgical procedures where the parietal pain effect that lasted from the first hour to twenty-four hours
peritoneum is a significant component that can contribute to after surgery.2 This is slightly different from what was found in
postoperative pain. In addition, this technique has minimal the case discussed, where an increase in pain perception was
complications and can be performed when neuro-axial found from 0-1 (in the first four hours after surgery) to 1-2
techniques are contraindicated. Multimodal pain regimens can (during 24 hours after surgery). Nonetheless, pain perception is
also be administered in operative procedures where TAP blocks subjective and further comprehensive studies can be carried out
are considered inadequate. One of the drawbacks of the TAP in similar settings to provide a more objective picture of pain
block (which is performed blindly using landmarks) is the high perception after a TAP block.4,14,15
incidence of failure. Even so, currently, there is an ultrasound that Apart from hernia surgery, the TAP block is also
can be used to assist in navigating the injection of anesthetic performed on operations involving the abdominal wall. One
agents, thereby increasing the success rate and reducing the retrospective study assessing the efficacy of TAP block in patients
failure rate because the accuracy of the distribution location of undergoing cholecystectomy assessed that the anti-pain effect
the anesthetic agent can be ensured.1,2 that was given could reduce the patient's perception of pain and
Deposition of the anesthetic agent was considered was able to reduce the administration of additional drugs as
successful if an anechoic appearance was seen between the rescue analgesics in patients who have low pain tolerance. In this
internal obliques and transversus abdominis muscles. An case report, the administration of TAP block can provide an anti-
anechoic picture indicates the presence of fluid in the form of an pain effect that makes the patient comfortable so that there is no
anesthetic agent which is injected with a needle that enters need for additional topical analgesic drugs that can be used to
between the transversus abdominis fields.4 treat pain that disturbs the patient's comfort.4,14
In this case, the patient has co-morbidities in the form
of a geriatric patient with a history of HHD which is characterized CONCLUSION
by hypertension resulting in rhythm disturbances (in this case The use of TAP block is considered to provide an
there were atrial fibrillation findings on the EKG examination) and effective and safe anti-pain effect in patients undergoing hernia
structural (there were LVH findings on the EKG examination and repair with comorbid geriatrics with a history of hypertensive
LVH cardiomegaly on chest x-ray). As a result of these heart disease (HHD), prevent cardiovascular complications, and
comorbidities, it can assess patients with ASA 3E physical status. speed up the time of postoperative patient mobilization.
Hemodynamics during observation in the HCU 24 hours

ACKNOWLEDGMENT
-
CONFLICT OF INTEREST
The author declare there is no conflict of interest.

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