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 Table of Contents  
LETTER TO THE EDITOR
Year : 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


Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Date of Web Publication29-Dec-2021

Correspondence Address:
Dr. Pankaj Singh Rana
Department of Anaesthesiology, Critical Care and Pain, 2nd Floor, Main Building, Tata Memorial Centre, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_44_21

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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;35:254-5

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 Jan 28];35:254-5. Available from: https://www.indianjpain.org/text.asp?2021/35/3/254/334102



Sir,

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: a) Image showing ultrasound anatomy of subcostal transverse abdominis plane (TAP), b) needle between posterior rectus sheath and transverse abdominis muscle, c) needle insertion for TAP block; and d) four catheters for four-quadrant TAP block

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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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vadhanan P, Hussain M, Prakash R. The subcostal nerve as the target for nerve stimulator guided transverse abdominis plane blocks – A feasibility study. Indian J Anaesth 2019;63:265-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Cata JP, Fournier K, Corrales G, Owusu-Agyemang P, Soliz J, Bravo M, et al. The impact of thoracic epidural analgesia versus four quadrant transversus abdominis plane block on quality of recovery after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy surgery: A single-center, noninferiority, randomized, controlled trial. Ann Surg Oncol 2021;28:5297-310.  Back to cited text no. 2
    
3.
Foster RH, Markham A. Levobupivacaine: A review of its pharmacology and use as a local anaesthetic. Drugs 2000;59:551-79.  Back to cited text no. 3
    
4.
Heppolette CA, Brunnen D, Bampoe S, Odor PM. Clinical pharmacokinetics and pharmacodynamics of levobupivacaine. Clin Pharmacokinet 2020;59:715-45.  Back to cited text no. 4
    
5.
Venkatraman R, Saravanan R, Dhas M, Pushparani A. Comparison of laparoscopy-guided with ultrasound-guided subcostal transversus abdominis plane block in laparoscopic cholecystectomy – A prospective, randomised study. Indian J Anaesth 2020;64:1012-7.  Back to cited text no. 5
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6.
Bhatia P, Bihani P, Chhabra S, Sharma V, Jaju R. Ultrasound-guided bilateral subcostal TAP block for epigastric hernia repair: A case series. Indian J Anaesth 2019;63:60-3.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Niraj G, Kelkar A, Hart E, Horst C, Malik D, Yeow C, et al. Comparison of analgesic efficacy of four-quadrant transversus abdominis plane (TAP) block and continuous posterior TAP analgesia with epidural analgesia in patients undergoing laparoscopic colorectal surgery: An open-label, randomised, non-inferiority trial. Anaesthesia 2014;69:348-55.  Back to cited text no. 7
    
8.
Doctor JR, Solanki SL, Bakshi S. Knotty Catheter! – An unusual complication of rectus sheath block. Indian J Anaesth 2019;63:947-8.  Back to cited text no. 8
[PUBMED]  [Full text]  


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