|Year : 2021 | Volume
| Issue : 1 | Page : 57-61
A comparative study of ultrasound-guided transversus abdominis plane block with local anesthetic infiltration in inguinal hernia repair: A prospective randomized study
Syed Hussain Amir1, Kumari Chitra1, Qazi Ehsan Ali1, Prabhash Chandra Jha2, Md Shahab Saquib1
1 Department of Anesthesiology, Jawaharlal Nehru Medical College, AMU, Aligarh, Uttar Pradesh, India
2 Department of Radiodiagnosis, Jawaharlal Nehru Medical College, AMU, Aligarh, Uttar Pradesh, India
|Date of Submission||03-Feb-2020|
|Date of Decision||14-Sep-2020|
|Date of Acceptance||04-Mar-2021|
|Date of Web Publication||27-Apr-2021|
Dr. Syed Hussain Amir
Department of Anesthesiology, Jawaharlal Nehru Medical College, AMU, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Transversus abdominis plane (TAP) block is a relatively newer block that provides analgesia to the parietal peritoneum, skin and muscles of the anterior abdominal wall. Aims: To determine the effectiveness of the TAP block over wound infiltration for hernia repair. Settings and Design: Randomized, double-blinded, prospective study in an academic teaching hospital. Methods: Sixty patients were divided into two groups of 30 each. In Group T, patients received ultrasound-guided TAP block for inguinal hernia repair whereas in Group I, local anesthetic infiltration at the wound site was done. Primary outcome measure was pain relief as assessed by a numeric rating scale (NRS) whereas secondary outcome measures were duration (from the time at which TAP block or local anesthetic infiltration is given to the time at which patient first requests for rescue analgesic) of post-operative analgesia, patient satisfaction score, and complications, if any. Results: Mean NRS score at 0hr for a group I was 0.88±0.74 and for group T was 0.68±0.70 with a p-value of 0.28 and the mean NRS score at 24hr for the group I was 4.47±0.66 and for group T was 4.54±0.62 with a p-value of 0.68 but at 2hr, 6hr and 12hr, the NRS was significantly more in group I (p < 0.05). Mean time of 1st analgesic request in group I was 403.73 minutes as compared to group T where it was 711.33 mins (P<0.001). The post-operative nausea and vomiting (PONV) and sedation in group I was significantly more than group T. Conclusion: Ultrasound-guided TAP block provides better postoperative analgesia both in quality and duration. TAP block reduces the opioid demand and opioid-related side effects like sedation and postoperative nausea vomiting and thus, improves overall patient satisfaction.
Keywords: Inguinal hernia, transversus abdominis plane block, ultrasound guided, wound infiltration
|How to cite this article:|
Amir SH, Chitra K, Ali QE, Jha PC, Saquib MS. A comparative study of ultrasound-guided transversus abdominis plane block with local anesthetic infiltration in inguinal hernia repair: A prospective randomized study. Indian J Pain 2021;35:57-61
|How to cite this URL:|
Amir SH, Chitra K, Ali QE, Jha PC, Saquib MS. A comparative study of ultrasound-guided transversus abdominis plane block with local anesthetic infiltration in inguinal hernia repair: A prospective randomized study. Indian J Pain [serial online] 2021 [cited 2021 Jun 15];35:57-61. Available from: https://www.indianjpain.org/text.asp?2021/35/1/57/314688
| Introduction|| |
Postoperative pain management is one of the significant components of overall perioperative care for anesthesiologists and surgeons alike. Failure to control acute postoperative pain can have significant unwanted physiological and psychological consequences such as patient dissatisfaction, discomfort, prolonged hospital stay, delayed rehabilitation, and can even progression to chronic pain. Furthermore, postoperative pain is one of the most common medical causes of delayed discharge (17%–40%). Considerable amount of postoperative pain is derived from anterior abdominal wall incision. Conventionally, opioids have been used to manage postoperative pain. However, opioid-related adverse events including respiratory depression, paralytic ileus, and sedation have led to a shift toward utilizing opioid -sparing techniques for postoperative analgesia.
Inguinal hernia repair is one of the most common surgeries performed on anterior abdominal wall. The incidence of postoperative pain in hernia repair varies between 0% and 37%. In the last two decades, peripheral nerve block has gained popularity for the management of acute postoperative pain. Transversus abdominis plane (TAP) block is a recent technique for the management of surgical abdominal pain. It involves injecting local anesthesia into the plane between the internal oblique and transversus abdominis muscle. We compared TAP block with local anesthetic infiltration for inguinal hernia repair. The purpose of the study was to decrease the dose of opioids as well as its side effect and to provide a better postoperative analgesia and comfort to the patient. We hypothesized that USG-guided TAP block was superior to local infiltration for postoperative analgesia in inguinal hernia repair.
| Methods|| |
Following Institutional Ethical Committee approval, this prospective randomized study was conducted on 60 adult patients undergoing elective hernia repair under general anesthesia from September 2018 to October 2019 at the Department of Anesthesiology and Critical Care of an academic teaching hospital [Figure 1]. The patients were divided into two groups of 30 each using computer-generated random number table. Allocation concealment was done by serially numbered opaque sealed envelopes technique. The sealed envelopes were opened on the day of surgery by a person not participating in the study. In Group T, patients received ultrasound guided TAP block at the side of inguinal repair whereas in Group I, patients received local anesthetic infiltration at the wound site.
Patients between 20 and 65 years of either sex, weighing 35–75 kg, American Society of Anesthesiologists 1 and 2 and open inguinal hernia repair were included in the study. Written informed consent was taken. Patients not giving consent, history of opioid allergy, coagulation disorder, previous or bilateral hernia repair were excluded.
Patients were premedicated with injection midazolam at a dose of 0.03 mg/kg, dexamethasone 0.15 mg/kg and fentanyl 1.5 mcg/kg of body weight. Perioperative monitoring was done by electrocardiography, pulse oximeter, noninvasive arterial blood pressure (BP) and capnography. After preoxygenation for 3 min, anesthesia was induced with inj. Propofol 2 mg/kg and injection Vecuronium 0.1 mg/kg. Orotracheal intubation was done with appropriate size cuffed endotracheal tube. Anesthesia was maintained by oxygen, nitrous oxide, injection vecuronium and isoflurane and 30 mg of intravenous ketorolac. After completion of surgery under general anaesthesia, under strict aseptic precautions, a linear 5–10 MHz ultrasound transducer was placed to the anterolateral abdominal wall of Group T patients where the three-muscle layer; external oblique, internal oblique, and transversus abdominis were most distinct. After identification of the TAP, the probe was moved to posterolaterally to lie across the midaxillary line just superior to the iliac crest (over the triangle of Petit). The 18G spinal needle was then introduced anteriorly and advanced in an in-plane approach. Between internal oblique and transversus abdominis, hydrodissection of fascial plane was done by normal saline and then 0.25% levobupivacaine in a dose of 1.5 mg/kg with a total volume of 20 ml was injected with intermittent aspiration [Figure 2]. The correct placement of the needle was confirmed by expansion of local anesthetic solution as a dark shadow between internal oblique and transversus abdominis muscles pushing the muscle.
After giving TAP block, residual neuromuscular paralysis was reversed using injection neostigmine 0.5 mg/kg and injection glycopyrrolate. After extubation, the patients were shifted to postoperative recovery room to look for any hemodynamic compromise. The patients were monitored until they become fully awake and became oriented to time, place, and person. The first recording was done at this point of time and it called it 0 h. Then the parameters were recorded at 2 h, 6 h, 12 h, and 24 h.
Similarly, in Group I, 0.25% levobupivacaine at a dose of 1.5 mg/kg with total volume of 20 ml were infiltrated by the surgeons after completion of the surgery.
Both the groups of patients were shifted after 30 min of procedure. All the patients were given injection tramadol at a dose of 2 mg/kg when numeric rating scale (NRS) score was 3 or more. Follow-up was done in the ward at 2 h, 6 h, 12 h, and 24 h period. Primary outcome measure was the pain relief as assessed by NRS whereas secondary outcome measures were duration (from the time at which TAP block and local anesthetic is given to the time at which patient first request for rescue analgesic) of postoperative analgesia, postoperative opioid requirement and sedation score, patient satisfaction score, and complication if any. Incidence of postoperative nausea and vomiting (PONV) was also recorded during 24 h postoperatively. PONV score was assessed as none = 0, mild nausea = 1, moderate nausea = 2, and vomiting = 3. Sedation score was assessed by Ramsay sedation score which is the 6 point score. The scoring is like: 0 Paralyzed, unable to evaluate, (1) Awake, (2) Lightly sedated, (3) Moderately sedated, follows simple command, (4) Deeply sedated, responds to non-painful stimuli. (5) Deeply sedated, responds only to painful stimuli, and (6) Deeply sedated, unresponsive to painful stimuli.
Patient satisfaction score during postoperative period was noted by Likert's scale. The scale included 5 Likert items: Very dissatisfied = 1, dissatisfied = 2, unsure = 3, satisfied = 4, and very satisfied = 5. Patients were enquired to verbally assign the score of the satisfaction scale.
Statistical analysis was done using IBM SPSS Statistics software, version 20 (SPSS Inc., Chicago, IL, USA) and Microsoft Excel of MS-Office 2016. Patients' demographic characteristics were analyzed using unpaired t-test and Chi-squared test and Fischer's exact test. The results were expressed in numbers, percentage, mean, and standard deviation as appropriately. Hemodynamic parameters pulse rate, BP and NRS, sedation score, PONV score, total tramadol required in 24 h and patient satisfaction score were analyzed using unpaired t-test and Chi-square test. A P < 0.05 was considered statistically significant.
| Results|| |
Demographic data such as age, weight, height, and gender were comparable in both the groups [Table 1].
The mean NRS score [Table 2] at 0 h, 2 h, 6 h, 12 h, and 24 h were analyzed between the two groups. It was comparable at 0 and 24 h. Mean NRS score at 0 h for a Group I was 0.88 ± 0.74 and for Group T was 0.68 ± 0.70 (P = 0.28). Mean NRS score at 24 h for the Group I was 4.47 ± 0.66 and for Group T was 4.54 ± 0.62 (P = 0.68) but at 2 h, 6 h and 12 h the NRS was significantly more in Group I (P < 0.05). At 2 h, mean NRS score for a Group I was 2.39 ± 0.81 and for Group T was 1.78 ± 0.81 (P = 0.005). At 6 h, mean NRS score for the Group I was 3.29 ± 0.43 and for Group T was 2.55 ± 0.72 (P < 0.001). At 12 h, mean NRS score for the Group I was 3.54 ± 0.44 and for Group T was 3.08 ± 0.52 (P < 0.001).
Rescue analgesic request in both the groups, Group I and T were compared [Table 3]. Mean time of 1st analgesic request in Group I was 403.73 min as compared to Group T where it was 711.33 min (P < 0.001). In Group T, only 1 patient required rescue analgesic at 2 h postoperative, whereas in Group I, nine patients required rescue analgesic at 2 h post operatively. Total tramadol required in 24 h period was also compared in both groups [Table 3]. It was 288.70 mg in Group T and 488.40 mg in Group I (P < 0.0001). It is evident that TAP block reduces the overall postoperative analgesic requirement and has got both opioid and nonsteroidal anti-inflammatory drug-sparing effect. There was also reduction in the incidence of side effects related to opioid consumption such as nausea, vomiting, and sedation.
PONV score was compared at 0 h, 2 h, 6 h, 12 h, and 24 h postoperatively. PONV score of 1 and 2 at 2 h and 2 at 12 h and 24 h was significantly more among Group I as compared to Group T [Figure 3]. The mean sedation score at 2 h, 6 h, 12 h and 24 h was also analyzed between the two groups. Mean sedation score at 2 h and 6 h between the two groups were comparable, but at 12 h and 24 h, there was a significant difference in mean sedation score in Group I than Group T [Figure 4]. Overall patient satisfaction score was assessed in both the groups. Ten out of 30 (33%) patients in Group T were very satisfied, 6 (20%) was satisfied, 10 (33%) was unsure, and 4 (13.33%) patients were dissatisfied, whereas in Group I only 1 (3.33%) patient was very satisfied, 8 (26.66%) were satisfied, 7 (23.33) were unsure, 9 (30%) were dissatisfied, and 5 (16.66) were very dissatisfied. No unwanted side effect of TAP block or local anesthetic infiltration had occurred in both the groups.
| Discussion|| |
TAP block is a newer type of peripheral nerve block which was first defined by Kuppuvelumani et al. in 1993 and formally recognized by Rafi in 2001 and is used for the management of surgical abdominal pain by injecting local anesthesia into the plane between the internal oblique and transversus abdominis muscle. The block described was a landmark-guided technique. It requires the detection of two pops, or loss of resistance, using a short-bevel needle to locate the facial layer. Liver injury and intraperitoneal injection have been reported after landmark-guided TAP block. Ultrasound guided TAP block first reported by Hebbard have improved the success rate of TAP block and helped in preventing injury to nearby anatomical structures. TAP block works by blocking the thoraco-lumbar nerves (T6–L1) which supply sensory fibers to the anterior abdominal wall. It has been used to provide analgesia for lower abdominal surgeries like hysterectomy, caesarean section, retropubic prostatectomy, laparoscopic cholecystectomy, and appendectomy.
Total tramadol required in 24 h period was significantly less in Group T than Group I. Our study was consistent with study done by Tolchard et al., in which they found that the mean pain scores at 1 h and 4 h were less in TAP block compared to port-site infiltration. Another study consistent with our study was done by Sivapurapu et al., between TAP block and direct infiltration of local anesthetic in lower abdominal gynecological surgery and they observed a reduction in VAS score in TAP block group in comparison to local infiltration group and also reduction total opioid requirement. A study was done by Suseela et al. in 2015 compared TAP block with port site infiltration of local anesthetic in laparoscopic cholecystectomy. In this study, they found that NRS for pain was zero at 1 h in both groups. That means port-site infiltration and TAP block are effective in providing analgesia in the 1st h. NRS was significantly lower in Group T compared to Group I at 2 h, 3 h, 6 h, 12 h, and 24 h. The request of first analgesic was significantly earlier in local anesthetic infiltration group and total tramadol required was also reduced in patients who had provided with TAP block, which is similar to our study. In another study done by Ortiz et al., there was no clinically significant difference in pain scores and postoperative analgesic requirement between TAP block and port-site infiltration even though the duration of analgesia and severity of pain were not assessed. This may be due to, only 15 ml of 0.5% ropivacaine in each side with the classic approach was used for TAP block.
Sedation was statistically significant in Group I as compared to Group T. Sivapurapu et al., also found similar finding, decreased in sedation in TAP block group compared to direct infiltration of local anesthetic group.
The incidence of PONV was statistically significant in Group I than group T. This may be due to higher tramadol requirement in Group I patient than Group T patients similar to study done by Sivapurapu et al., in which they observed a reduction in the incidence of postoperative nausea vomiting too. In the study done by Amr and Amin there was also a reduction in incidence of postoperative nausea vomiting in TAP block. In contrast Aveline et al., could not account any difference in PONV incidence in TAP block group and ileo-inguinal/ileo-hypogastric nerve block group. This may be because of reduction in NRS score of TAP block group compared to ilio-inguinal/iliohypogastric nerve block, but the difference was not significant and so the opioid consumption and incidence of PONV was not significant.
Patients were more satisfied with the TAP block than wound filtration technique. This is due to longer duration of pain relief and lesser incidence of nausea and vomiting in TAP group. Our study has an ultrasound-guided approach, so there were no procedural complications.
Our study had certain limitations. It has a small sample size. The subjects were not followed up long term for the incidence of chronic pain. While all measures to conceal the group al-location were taken, true blinding may not have been possible since subjects in the study group reported less pain and we did not document the pain score on movement.
| Conclusion|| |
Ultrasound-guided TAP block provides better postoperative analgesia both in quality and duration. TAP block reduces the opioid requirement and opioid-related side effects such as sedation and postoperative nausea vomiting and thus improving overall patient satisfaction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]