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 Table of Contents  
Year : 2022  |  Volume : 36  |  Issue : 2  |  Page : 103-107

Ultrasound guided rectus sheath and transverse abdominis blocks for robotic urological surgeries – A case series

Department of Anaesthesia, VMMC and Safdarjung Hospital, New Delhi, India

Date of Submission02-Feb-2022
Date of Decision07-Apr-2022
Date of Acceptance13-Apr-2022
Date of Web Publication25-Aug-2022

Correspondence Address:
Dr. Divya Rani
C-602, Shri Durga Society, Dwarka Sector 11, New Delhi - 110 075
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpn.ijpn_10_22

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Background: Robotic surgeries have improved perioperative outcomes. We have combined ultrasound (USG) guided bilateral rectus sheath (RS) block along with transverse abdominis plane (TAP) block to assess perioperative opioid requirement, visual analog scale (VAS) score, and modified Post Anesthetic Discharge Scoring System (PADSS) criteria for robotic urological surgeries. Ultrasound (USG)-guided blocks were given bilaterally after induction of general anesthesia. Methods: A total of ten patients scheduled for robotic urological surgeries were administered 30 ml of 0.25% bupivacaine (2.5 mg kg-1) with 0.75 mcg kg-1 of clonidine (10 ml of drug was given for TAP block and 5 ml of drug for RS block on each side) after negative aspiration. Results: Supplemental opioid was not required perioperatively, and 9 out of 10 patients were pain free (VAS score <3) for at least 6 h. Ten patients had a modified PADSS score ≥10 after 6 h of surgery. Conclusion: USG combined TAP and RS blocks is a promising technique with low learning curve, excellent analgesia, reduced opioid consumption, and higher PADSS score in the perioperative period.

Keywords: Opioid requirement, Post Anesthetic Discharge Scoring System score, rectus sheath block, robotic surgery, transverse abdominis plane block, urological, visual analog scale score

How to cite this article:
Rani D, Aggarwal S, Gupta A, Mudgal P. Ultrasound guided rectus sheath and transverse abdominis blocks for robotic urological surgeries – A case series. Indian J Pain 2022;36:103-7

How to cite this URL:
Rani D, Aggarwal S, Gupta A, Mudgal P. Ultrasound guided rectus sheath and transverse abdominis blocks for robotic urological surgeries – A case series. Indian J Pain [serial online] 2022 [cited 2022 Sep 29];36:103-7. Available from: https://www.indianjpain.org/text.asp?2022/36/2/103/354716

  Introduction Top

Pain relief is crucial in the perioperative period. Acute pain management is essential for patient to prevent the development of neuropathic pain. Traditional perioperative analgesia using intravenous opioids can lead to nausea, vomiting, ileus, constipation, sedation, urinary retention, delirium, respiratory depression, and postoperative dementia, especially in geriatric population. Hence, regional analgesia as per the (Enhanced Recovery after Surgery) protocols is being increasingly used as an adjunct for perioperative pain management.[1] Robotic urological surgeries such as prostatectomy, radical/partial nephrectomy, ureterectomy, and pyeloplasty are increasingly being performed using the Da Vinci Xi system (Intuitive Surgical, CA). Robotic surgeries are technically advanced, providing improved visualization, precise incision, minimally invasive, decreased blood loss, and early recovery. Pain in robotic surgeries can be somatic, visceral, and due to the creation of carboperitoneum.[2] Port positions are variable depending on the procedures performed and also involve the midline supraumbilical region. For robotic-assisted pelvic surgeries, ports are placed in an umbrella fashion. The first camera port is placed 1 cm above the umbilicus, two ports on the left side 4 cm apart, one robotic arm 4 cm away from the camera port horizontally on the right side, the 12-mm assistant port is placed in a triangle between the camera port, first robotic port on the right, and a 5-mm assistant port is placed 3 cm above the iliac crest[3] [Figure 1] and [Figure 2]. In robotic abdominal surgeries, the assistant port (12 mm) is placed 3–4 cm above the umbilicus and four robotic arm ports (8 mm) are placed 6 cm apart at the lateral edge of the rectus muscle in a linear manner. The largest 12-mm assistant port is the first port to be placed in the supraumbilical region for any robotic urological surgery [Figure 3]. The sole use of transverse abdominis plane (TAP) block provides inadequate anterior abdominal wall analgesia (T10-L1) for robotic urological surgeries. Supplemental rectus sheath (RS) block provides additional dermatomal coverage (T6-T11), especially in the supraumbilical midline region.[4]
Figure 1: Robotic prostatectomy

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Figure 2: Robotic ureterectomy

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Figure 3: Robotic partial nephrectomy

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The T6-T11 nerves continue anteriorly from the transversus plane to pierce the RS and end as anterior cutaneous nerves innervating the supraumbilical region in the midline which are targeted in RS blocks. As per the literature available, mainly TAP block has been used for robotic urological procedures which do not cover the terminal nerve endings (anterior cutaneous nerves) under the rectus muscle in the midline.[5] Hence, in this case series, we studied that ultrasound (USG)-guided combined RS and TAP blocks are superior to supplemental intravenous opioids for complete perioperative anterior abdominal wall analgesia.

  Methods Top

A total of ten American Society of Anesthesiology I and II patients undergoing robotic urological surgeries were included in this case series, among which 6 were males (M) and 4 were females (F) [Table 1]. Visual Analog Scale (VAS) [Appendix 1] score was explained to the patient in an understandable language. Standard written informed consent was taken from all the patients for USG-guided RS and TAP blocks as a part of anesthetic technique. After preoxygenation with 100% oxygen for 3 min, intravenous induction of general anesthesia was done using injection (Inj.) fentanyl 2 mcg kg-1, Inj. propofol 2 mg kg-1, and Inj. atracurium 0.5 mg kg-1. Oxygen 40%, nitrous oxide 60%, and isoflurane were used as inhalational agents for maintenance. Ultrasound-guided TAP (lateral approach) and RS block were given by experienced anesthesiologist (consultant with 5 years of experience after postgraduation) using a SonoPlex echogenic 21G 80-mm needle under aseptic conditions. In the RS block, scanning was performed using a high-frequency linear USG probe (7–11 Hz) placed above the umbilicus at T8 level tracing laterally from the linea alba. After identifying the rectus muscle , using in-line approach the needle was inserted from the lateral border of rectus muscle advancing medially in the plane between rectus muscle and posterior sheath involving T6-11 dermatomes (anterior cutaneous nerves) [Figure 4].[5] In the TAP block, a linear transducer is placed on the midaxillary line between the subcostal margin and the iliac crest. The target was the fascial plane between the internal oblique and the transversus abdominis muscles, covering dermatomes T10-L1 (intercostal nerves T9-T11, subcostal nerve T12, and ilioinguinal and iliohypogastric nerves L1)[6] [Figure 5]. After confirming the position by hydrodissection, a total of 30 ml of 0.25% bupivacaine (2.5 mg Kg-1) with 0.75 mcg Kg-1 clonidine as adjuvant was administered bilaterally after negative aspiration (10 ml for TAP block and 5 ml for RS block on each side, respectively). All the patients were monitored for supplemental opioid requirements during the surgery by hemodynamic instability (20% change in heart rate and mean blood pressure from baseline). Postoperatively, the pain was assessed using VAS score (on a scale of 0–10) hourly for 6 h and modified Post Anesthetic Discharge Scoring System (PADSS) score after 6 h of surgery completion [Appendix 2]. In this case series, we found that none of the patients required supplemental analgesia during the intraoperative period. The mean duration of the surgeries was 2.5 h. In the postoperative period, 9 out of ten patients were pain free (VAS score <3) for at least 6 h. However, one patient had a VAS score of 5‒6 h after surgery and was administered Inj. ketorolac 30 mg intravenous as rescue analgesia. All the ten patients had a modified PADSS score ≥10 after 6 h of completion of surgery [Table 2].
Table 1: Visual Analog Scale score

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Table 2: Modified Post Anesthetic Discharge Scoring System score

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Figure 4: Transverse abdominis plane block

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Figure 5: Rectus sheath block

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  Discussion Top

In many studies conducted previously, USG-guided single block technique was used (TAP or RS block) individually. Rogers et al., Taninishi et al., Shahait and Lee and Chiancone, et al. studied USG-guided TAP block for robotic urological surgeries. They concluded that USG-guided TAP block decreases opioid requirement and pain scores perioperatively similar to our results.[6],[7],[8],[9] RS blocks were primarily used as an analgesic adjunct for umbilical hernia repair or laparoscopic gynecological procedures. However, more recent indications include analgesia for vertical midline laparotomy incisions for either lower or upper abdominal surgery.[10] Hamid et al. and Shim et al. studied USG-guided RS block in laparoscopic surgeries and found a decrease in pain scores perioperatively similar to our results. As per the sites of port placements, we found that RS block has an additive analgesic effect along with TAP block.[11],[12] None of the studies have been conducted so far using USG guided combined TAP and RS blocks bilaterally. We conducted our case series and found that the patients undergoing combined USG-guided RS and TAP blocks bilaterally have shown less perioperative opioid consumption, better VAS scores, and higher PADSS score in the postoperative period.

Limitations of our case series included a smaller sample size and no previously published data. Hence, we need to conduct further studies and include a larger sample size.

  Conclusion Top

USG guided RS and TAP blocks are promising and cost-effective techniques resulting in excellent analgesia (lower VAS score), reduced morbidity, reduced opioid consumption, and higher PADSS score in the perioperative period for patients undergoing robotic urological procedures.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Batley SE, Prasad V, Vasdev N, Mohan-S G. Post-operative pain management in patients undergoing robotic urological surgery. Curr Urol 2016;9:5-11.  Back to cited text no. 1
Chang C, Steinberg Z, Shah A, Gundeti MS. Patient positioning and port placement for robot-assisted surgery. J Endourol 2014;28:631-8.  Back to cited text no. 2
Corona-Montes VE, González-Cuenca E, Fernández-Noyola G, Rueda-Loaiza JA, Ramírez-Muciño JA, Vázquez-Lavista LG. Robot-assisted radical prostatectomy our technique description. J Urol Nephrol Stud 2020;3:236-41. Available from: https://lupinepublishers.com/urology-nephrology-journal/pdf/JUNS.MS.ID.000153.pdf. [Last accessed on 2020 Oct 31].  Back to cited text no. 3
Kallingal GJ, Swain S, Darwiche F, Punnen S, Manoharan M, Gonzalgo ML, et al. Robotic partial nephrectomy with the Da Vinci Xi. Adv Urol 2016;2016:9675095.  Back to cited text no. 4
Uppal V, Sancheti S, Kalagara H. Transversus abdominis plane (TAP) and rectus sheath blocks: A technical description and evidence review. Curr Anesthesiol Rep 2019;9:479-87.  Back to cited text no. 5
Shahait M, Lee DI. Application of TAP block in laparoscopic urological surgery: Current status and future directions. Curr Urol Rep 2019;20:20.  Back to cited text no. 6
Rogers T, Bhat KR, Moschovas M, Onol F, Jenson C, Roof S, et al. Use of transversus abdominis plane block to decrease pain scores and narcotic use following robot-assisted laparoscopic prostatectomy. J Robot Surg 2021;15:81-6.  Back to cited text no. 7
Taninishi H, Matsusaki T, Morimatsu H. Transversus abdominis plane block reduced early postoperative pain after robot-assisted prostatectomy: A randomized controlled trial. Sci Rep 2020;10:3761.  Back to cited text no. 8
Chiancone F, Fabiano M, Ferraiuolo M, de Rosa L, Prisco E, Fedelini M, et al. Clinical implications of transversus abdominis plane block (TAP-block) for robot assisted laparoscopic radical prostatectomy: A single-institute analysis. Urologia 2021;88:25-9.  Back to cited text no. 9
Melesse DY, Chekol WB, Tawuye HY, Denu ZA, Agegnehu AF. Assessment of the analgesic effectiveness of rectus sheath block in patients who had emergency midline laparotomy: Prospective observational cohort study. Int J Surg Open 2020;24:27-31.  Back to cited text no. 10
Hamid HK, Ahmed AY, Alhamo MA, Davis GN. Efficacy and safety profile of rectus sheath block in adult laparoscopic surgery: A meta-analysis. J Surg Res 2021;261:10-7.  Back to cited text no. 11
Shim JW, Jung S, Moon HW, Lee JY, Park J, Lee HM, et al. Rectus sheath block for acute pain management after robot assisted laparoscopic prostatectomy. Asian J Surg 2021;44:1015-6.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2]


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