Indian Journal of Pain

: 2021  |  Volume : 35  |  Issue : 3  |  Page : 254--255

Four-quadrant transverse abdominis plane block: A relatively new frontier for postoperative analgesia after major abdominal surgery

Pankaj Singh Rana, Reshma P Ambulkar, Manoj Maji, Sohan Lal Solanki 
 Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Correspondence Address:
Dr. Pankaj Singh Rana
Department of Anaesthesiology, Critical Care and Pain, 2nd Floor, Main Building, Tata Memorial Centre, Mumbai - 400 012, Maharashtra

How to cite this article:
Rana PS, Ambulkar RP, Maji M, Solanki SL. Four-quadrant transverse abdominis plane block: A relatively new frontier for postoperative analgesia after major abdominal surgery.Indian J Pain 2021;35:254-255

How to cite this URL:
Rana PS, Ambulkar RP, Maji M, Solanki SL. Four-quadrant transverse abdominis plane block: A relatively new frontier for postoperative analgesia after major abdominal surgery. Indian J Pain [serial online] 2021 [cited 2022 May 29 ];35:254-255
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Postoperative pain after major abdominal surgery is a challenge to treat effectively balancing the benefits and side effects of the technique used. On one side adequate pain control is not only the patient's right but a requirement to prevent detrimental effects on the recovery leading to morbidity as well as to prevent the persistent or chronic postsurgical pain syndrome recently getting favorable response is ultrasound-guided (USG) truncal blocks. Transverse abdominis plane (TAP) block provides an alternative to epidural analgesia, specifically in cases where putting an epidural catheter is contraindicated or not feasible such as infection at the site of insertion, sepsis, coagulopathy, or fixed cardiac output states.[1] The four-quadrant TAP block has recently gain popularity in open as well as laparoscopic abdominal surgeries and found to be an effective tool of postoperative analgesia similar to thoracic epidural analgesia.[2]

Levobupivacaine local anesthetic is generally well tolerated except that a dose adjustment may be needed in the elderly. Levobupivacaine is a long-acting local anesthetic with a clinical profile closely resembling that of bupivacaine. However, current safety and toxicity data show an advantage for levobupivacaine over bupivacaine because it is less cardiotoxic.[3],[4]

We hereby wish to share, postoperative analgesia management in two patients who underwent major abdominal surgery where conventional neuraxial blockade was a dilemma. First, a 65-year-old female known case of hypertension, diabetes, and hypothyroid, who underwent inferior vena cava (IVC) sarcoma excision. The tumor mass on computerized tomography scan was 14 cm × 9.3 cm × 8.4 cm arising from intrahepatic IVC, encasing the descending aorta with angle of contact >180° with a filling defect noticed in the right external and internal iliac and right common femoral vein suggestive of thrombus. Furthermore, Doppler USG was suggestive of acute thrombus involving right external iliac vein, common femoral vein, and superficial femoral vein. Preoperatively, she was started on therapeutic dose of enoxaparin, with an advice to restart enoxaparin again on 1st postoperative day (POD).

The second case was a 55-year-old male who underwent retroperitoneal sarcoma resection, iliofemoral artery, and vein reconstruction, left ureterolysis with DJ stenting, and required intraoperative as well as postoperative anticoagulation.

Surgical incision in both patients was extending from xiphisternum to pubic symphysis. The extensive origin of the nerves that must be blocked to provide analgesia for large abdominal incision poses significant problems in the search for suitable regional anesthesia techniques. The abdominal wall is supplied by the lower six thoracic and upper two lumbar sensory nerves, either through extensions of the intercostal branches or, for the more caudal nerves, through the musculature of the abdominal wall. Intraoperative analgesia was maintained with infusion of fentanyl in our patients. In our institute, epidural analgesia would be the method of choice but in these cases, because it was not feasible, we had to look for alternative way to achieve good analgesia in the postoperative period. With epidural analgesia and nonsteroidal anti-inflammatory drugs (NSAIDs) (massive blood loss, around 5 l in both cases) not an option, and growing evidence supporting the effectiveness of TAP blocks for various types of abdominal surgeries, a “Four-quadrant TAP block” was thought as a good option. Subcostal TAP block is effective for upper abdominal surgery where the surgical incision extends from T6 to T10 dermatomes. Posterior TAP block is effective in providing analgesia after lower abdominal surgery where the incision extends from T10 to L1 dermatomes. Before extubation, under GA, USG-guided four-quadrant TAP blocks were performed and four catheters were inserted and tunneled [Figure 1]. About 15 ml of 0.2% levobupivacaine was given every eight hourly through each catheter for 4 consecutive days. The pain was assessed by our acute pain service team in the postoperative period. As part of multimodal analgesia, both received paracetamol 8 hourly for 4 days, tramadol 8 hourly for first 24 h following surgery, and single dose of NSAIDs on POD 2 and 3 for first case only. Worst numerical rating scale pain scores was 2 at rest and 3 on movement in first case and 3 at rest and 4 on movement in the second case, sedation and nausea score was 0 in the first 72 h postoperatively the patients had no difficulty in performing respiratory rehabilitation and mobilization in the postoperative period. The TAP catheters were removed on POD 4 and both patients were discharged on POD 6. Patient satisfaction scores were found to be 9 out of 10. One of the drawbacks of TAP block is that it does not cover visceral pain. Almost 75%–80% of the pain after abdominal surgery is somatic in origin[5] and furthermore the proportion of visceral pain reduces after 24 h. In both the cases, visceral component was not thought to be a major problem.{Figure 1}

The four-quadrant TAP block helps in providing analgesia to the entire anterior abdominal wall including the parietal peritoneum.[6],[7] Care must be taken removal of these catheters as truncal blocks such as rectus sheath catheter can get entangled on itself and lead to knotting and need intervention.[8]

In summary, the four-quadrant TAP block has a role in managing postoperative pain following major abdominal surgeries with extended surgical incision as part of a multimodal analgesic plan, especially with the current evidence of epidural analgesia no longer remaining the gold standard.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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