|Year : 2014 | Volume
| Issue : 1 | Page : 51-58
Ultrasound-guided ipsilateral transverse abdominis plane and ilioinguinal-iliohypogastric nerve block for inguinal hernia repair in patients with liver cirrhosis
Rasha S Bondok, Rania M Ali
Departments of Anesthesia and Intensive Care, Ain-Shams University, Cairo, Egypt
|Date of Web Publication||31-May-2014|
Rasha S Bondok
MD, Department of Anesthesia and Intensive Care, Ain-Shams University, 33 Hassan Maamoun St, Nasr City, Postcode 11391, Cairo
Source of Support: None, Conflict of Interest: None
Patients with liver cirrhosis have a limited hepatic reserve and are vulnerable to surgical and anesthetic stress. The purpose of the present study was to observe the effect of combining ultrasound-guided ipsilateral transverse abdominis plane block with ilioinguinal-iliohypogastric block as a sole anesthetic technique for inguinal hernial repair in a series of chronic liver patients with cirrhosis.
Materials and methods
Twenty-nine male patients having chronic liver disease with cirrhosis underwent elective inguinal hernia repair, with inclusion criteria of American Society of Anesthesiologists physical status classification groups II or III and age between 40-75 years. All patients were with chronic liver disease and liver cirrhosis, having a Child-Pugh class B or Moemen modified classification of liver disease class B and an international normalized ratio not exceeding 1.5.
No patients necessitated the conversion to general anesthesia and only three patients (10%) needed local anesthetic infiltration. Cardiorespiratory parameters were stable throughout the study period. Patients had a significantly low visual analog scale for pain in the first 6 h postoperatively (P<0.001). Mean duration of postoperative analgesia was 13.16 ± 4.5 h. No patients (0%) required rescue analgesia in the first 6 h postoperatively, whereas 16 patients (55.17%) required rescue analgesia in the following next 6 h postoperatively and 11 patients (37.9%) required rescue analgesia between 18 and 24 h postoperatively. Patients reported a high median satisfaction score of 6 (5-7).
This study showed the feasibility of combined ultrasound-guided transverse abdominis plane and ilioinguinal-iliohypogastric nerve block as a sole anesthetic technique for inguinal hernia repair in patients with liver cirrhosis as well as for providing postoperative analgesia and early ambulation.
Keywords: Block, ilioinguinal, liver, transverse abdominis
|How to cite this article:|
Bondok RS, Ali RM. Ultrasound-guided ipsilateral transverse abdominis plane and ilioinguinal-iliohypogastric nerve block for inguinal hernia repair in patients with liver cirrhosis. Ain-Shams J Anaesthesiol 2014;7:51-8
|How to cite this URL:|
Bondok RS, Ali RM. Ultrasound-guided ipsilateral transverse abdominis plane and ilioinguinal-iliohypogastric nerve block for inguinal hernia repair in patients with liver cirrhosis. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2021 Oct 25];7:51-8. Available from: http://www.asja.eg.net/text.asp?2014/7/1/51/128409
| Introduction|| |
Inguinal hernia repair is one of the most common procedures in general surgery. Patients with a cirrhotic liver accompanied by ascites show an increased incidence rate of inguinal hernias in comparison with the general population. An increase in abdominal pressure plays a role in promoting the occurrence of this disease entity .
Patients with liver cirrhosis have a limited hepatic reserve and are vulnerable to physiological stress. There can be profound derangement of nearly every physiological system. Furthermore, it is possible to observe an increased risk for postoperative liver decompensation and possible impairment of wound healing because of frequent bad nutritional state of the patients . Surgical and anesthetic interventions may exacerbate liver dysfunction and result in life-threatening hepatic failure .
General and neuroaxial anesthesia can reduce mean arterial pressure and thereby reduce hepatic blood flow and relative hypoperfusion or lead to hypoxemia, which may produce further hepatocellular injury and result in decompensation . Coagulation defects in liver cirrhosis arise from thrombocytopenia, platelet dysfunction, and decreased levels of circulating clotting factors; thus, regional techniques need to be considered carefully as most patients suffer some form of coagulopathy, and epidural varices can pose an additional risk .
Inguinal hernia repairs can be performed by stepwise local infiltration anesthesia; however, it is rarely used. One of the explanations to this may be intraoperative patient discomfort and pain; other reasons may be related to tradition and surgeon preferences .
Regional ilioinguinal blockade has been recently used. Although generally used for the provision of postoperative analgesia, the block may be also used in specific scenarios instead of general anesthesia (GA) in high-risk patients . As with many other regional anesthetic techniques, the use of ultrasound guidance should be considered to ensure correct needle location and to improve the accuracy of the technique while limiting the potential for inadvertent damage to the intraperitoneal structures, especially in this category of patients .
Hernia repair induces parietal pain depending on the iliohypogastric and ilioinguinal nerves distribution. Both iliohypogastric and ilioinguinal nerves emanate from the first lumbar spinal root ,. In addition, the ventral rami of the lower intercostal nerves (T11 and T12) pierce the transverse abdominus muscle to lie between it and the internal oblique [Figure 1]. These latter nerves also supply sensation to the inferior abdominal wall, and block of these nerves by transversus abdominis plane (TAP) block and by iliohypogastric and ilioinguinal nerves is essential to provide anesthesia for procedures involving the lower abdominal wall . In addition, the location of the iliohypogastric and ilioinguinal nerves varies with frequent division of the nerves at the level of the iliac crest. The site of penetration of the two nerves toward the abdominal wall muscles also varies; hence, the more proximal the nerves are blocked, the more effective the block could be. Nerve endings anesthetized by the TAP block originate from T7 to L1 and include the iliohypogastric nerve (IHN) .
To improve intraoperative anesthesia in this population, a combined ultrasound-guided ilioinguinal-iliohypogastric (ILIH) block with ipsilateral transverse abdominis (TAP) block was the rational; there are no data from previous studies to support this approach in adults. The purpose of the present study was to observe the effect of combining ipsilateral TAP block with ILIH block as a sole anesthetic technique for inguinal hernial repair in a series of chronic liver patients with cirrhosis.
| Materials and methods|| |
The study was approved by the Research Ethical Committee at Ain-Shams University. Informed consent was obtained from all patients. From 2011 to 2013, 29 male patients having chronic liver disease with cirrhosis underwent elective inguinal hernia repair, with inclusion criteria of American Society of Anesthesiologists (ASA) physical status classification groups II or III and age between 40 and 75 years. All patients were with chronic liver disease and liver cirrhosis, having a Child-Pugh classification of liver disease  class B with a score not exceeding 8/15, Moemen modified classification of liver disease  class B, and an international normalized ratio not exceeding 1.5.
Exclusion criteria included recurrent hernia, bilateral hernia, patients with Child-Pugh class C or more than 8/15, international normalized ratio greater than 1.5, tense or refractory ascites, and serum sodium less than or equal to 120 meq/l. Patients with a BMI of greater than or equal to 40 kg/m 2 , known allergy to any of the medicines used, renal or cardiovascular dysfunction, bronchial asthma, hematological disorders (other than secondary to chronic liver disease), and regional block refusal were also excluded.
We evaluated the serum levels of liver enzymes preoperatively: aspartate aminotransferase, alanine aminotransferase, serum albumin, total bilirubin, serum creatinine, blood urea nitrogen, serum urea, and serum sodium.
The amount of ascites was determined on the basis of preoperative abdominal ultrasound. The amount of ascites was categorized into three groups (mild - few collections of fluid; moderate - multiple collections of fluid; and severe but not tense-generalized fluid, floating bowel).
Patients were instructed on the proper use of the visual analog scale (VAS). Using a 0-10 cm VAS, the patients rated their pain intensity, where score 0 = no pain and 10 = worst pain ever experienced. The Observer's Assessment of Alertness/Sedation scale was used to rate the alertness of the patient intraoperatively, where 5 = responds readily to name spoken in normal tone (awake/alert), 4 = lethargic response to name spoken in normal tone, 3 = responds only after name spoken loudly or repeatedly, 2 = responds after mild prodding or shaking, and 1 = does not respond to mild prodding or shaking (asleep/unarousable) .
In the induction room, intravenous access was established and an infusion of Ringer acetate was started. Patients were given intravenous 0.5 μg/kg of fentanyl and 0.03 mg/kg of midazolam for anixiolysis. In addition, intravenous 40 μg/kg of granisetron and 40 mg pantoprazole sodium were given 1 h before surgery. All patients received metronidazole 500 mg and ceftriaxone 1000 mg as antibiotic prophylaxis before skin incision. Platelet replacement was performed in patients whose platelet counts were less than or equal to 50 × 10 3 /μl.
Standard ASA monitoring were used throughout the surgery; heart rate (HR), noninvasive mean arterial blood pressure (MAP), and oxygen saturation (SpO 2 ) were documented at 5-min intervals. A nasal prong was applied and supplemental oxygen at 4 l/min of fresh gas flow was given throughout the procedure.
It was made clear to the patients that any pain, discomfort, or anxiety would be dealt with by the administration of local anesthetic (LA) infiltration with bupivacaine 0.25% during the operation or, if needed, by conversion to GA.
Patients were positioned supine. After skin disinfection with 5% alcoholic povidone-iodine solution, US-guided ipsilateral TAP block and ILIH block were provided using Mindray M5 ultrasound (Mindray DS USA Inc., Mahwah, New Jersey, USA). A linear high-frequency probe (7.5 MHz) was used to scan the abdominal wall in the multibeam mode. The edge of the probe was covered by a sterile plastic transducer sheath, and a sterile gel was applied on the skin.
Ilioinguinal and iliohypogastric nerve block
Before ultrasound examination was started, the following skin landmarks were indicated: anterior superior iliac spine (ASIS), ilioinguinal ligament, and the line connecting the ASIS with the umbilicus. The ASIS was the standard starting position from which the transducer was moved along the ASIS-umbilicus line. A local infiltration was performed with 1 ml of 1% lidocaine. Under continuous ultrasound guidance, a 20 G needle was advanced using an inplane (long axis) technique and the ILIH nerves were identified and located in the fascia compartment between the internal oblique and the transverse abdominis or external oblique muscles; the two nerves appeared as hypoechoic structures highlighted by the hyperechoic surrounding fascia and fat. Under real-time ultrasound imaging to verify the correct needle-tip position and spread of injected fluid, 10 ml bupivacaine 0.25% was injected around the nerves, and after needle adjustment a further 10 ml of the LA was injected.
Transverse abdominis plane block
The ultrasound probe was initially positioned in a transverse plane between the lower costal margin and the iliac crest in the midaxillary line. The orientation of the probe was perpendicular to a line joining the ASIS and the subcostal margin to obtain a transverse view of the abdominal layers. The probe was tilted, rotated, or both (rocking movement) to improve visualization of the three layers of the lateral abdominal wall, respectively, from superficial to the depth - external oblique, internal oblique, transversus abdominis, and, most deeply, peritoneal cavity. After local infiltration with 1 ml of 1% lidocaine, a 20 G needle was advanced using the inplane insertion with ultrasound real-time assessment from an anteromedial to a posterolateral direction. The progression of the needle, visible as a bright hyperechoic line, was assessed under direct ultrasonography. The injection site was defined between the aponeurosis of the internal oblique and transversus abdominis muscles. During insertion, the transducer was moved with careful manipulation to continuously visualize the shaft and tip of the needle and the fore-mentioned structures. If necessary, saline 0.9% (1 ml) was injected to optimize the tip location with small in-and-out movements. When the tip was correctly located in the targeted plane, 30 ml bupivacaine 0.25% was injected with intermittent aspiration, and the correct placement of the needle was confirmed by expansion of the LA solution seen as a hypoechoic shadow pushing the two layers apart (hydrodissection) between aponeurosis of the internal oblique and the transversus abdominis muscle.
All blocks were performed and supervised by an anesthesiologist experienced in ultrasound-guided regional anesthesia. The end of injection was considered the time for evaluating the effectiveness of the block. Sensory block was assessed every 3 min following completion of LA administration by pinprick sensation using a 23 G needle and by thermal sensation using an alcohol swab in the skin area overlying the surgical field. The sensory block was considered successful when there was a complete lack of pinprick and loss of cold sensation in the skin area overlying the surgical field. Upon reaching an effective sensory block, intraoperative sedation with propofol (diprivan 2%, AstraZeneca Pharmaceuticals Ltd, London, UK) at an initial loading dose of 0.5 mg/kg was given over a 10-min period followed by a maintenance dose of 1.5 mg/kg/h. Propofol was titrated as required to attain an Observer's Assessment of Alertness/Sedation scale of 4. All patients received 1 and/or 2 U fresh frozen plasma and tranexamic acid 10 mg/kg before skin incision.
After completion of the surgical procedure, patients were transferred to the postanesthetic care unit (PACU). After fulfilling an Aldrete score of greater than or equal to 9, patients were discharged from PACU to an intermediate care unit for 24 h.
The following measures were assessed and recorded:
- HR, MAP, and SpO 2 were recorded every 5 min throughout the intraoperative period, during the immediate postoperative period at 15 and 30 min, and at discharge from the PACU; baseline measurements were obtained just before the initiation of regional nerve block.
- The onset of sensory block was defined as the time from injection of local anesthesia to complete absence of thermal distinction and pain.
- Need of LA infiltration into surgical field or the conversion to GA was assessed.
- Surgical duration that corresponded to the time from skin incision until skin closure was recorded.
- In the PACU, the Modified Aldrete Score  was assessed every 5 min until discharge. Patients were ready for discharge upon achieving an Aldrete score of greater than or equal to 9. Time to achieve an Aldrete score of greater than or equal to 9 corresponded to the time from arrival to the PACU until discharge to the intermediate care unit.
- The degree of pain was evaluated using the VAS for pain hourly for the first 6 h and at 12, 18, and 24 h postoperatively.
- Duration of analgesia was defined as the time from leaving the operation theater to the first complaint of pain (Pain Score≥4) necessitating the need of rescue analgesia. Pain (VAS≥4) was treated with intravenous acetominophen (Perfalgan 10 mg/ml solution; Bristol-Myers Squibb Pharmaceuticals Ltd, Middlesex, UK) 1 g as a rescue analgesic, with a maximum daily dose not exceeding 3 g. The total 24 h analgesic consumption was calculated.
- Any adverse events including bradypnea (Respiratory Rate (RR) < 10 bpm), SpO 2 reaching 92% or less, hypotension (MAP < 55 mmHg), nausea, and vomiting were recorded.
- Patient ambulation time (out of bed time) was assessed hourly from completion of surgery until the time of the first ambulation out of bed.
- Liver enzyme levels and functions were measured 24 h postoperatively.
- Patients were asked to rate their satisfaction with the anesthesia and analgesia received using a seven-point Likert-like verbal rating scale , where 1 = extremely dissatisfied, 2 = dissatisfied, 3 = somewhat dissatisfied, 4 = undecided, 5 = somewhat satisfied, 6 = satisfied, and 7 = extremely satisfied. This assessment of patients' satisfaction was performed 6 h after leaving the PACU.
- An overall surgeon satisfaction was recorded, where a score of 1 = excellent, 2 = good, 3 = poor, and 4 = bad.
Recorded data were analyzed using statistical package for social sciences, version 20 (SPSS Inc., Chicago, Illinois, USA). Normality of quantitative data distribution was tested using the Shapiro-Wilk test. Normally distributed numerical data were presented as mean±SD, percentages, and numbers as appropriate. Within group differences were compared parametrically using the paired sample t-test, the Mann-Whitney U-test, and the χ2 -test (with Yates correction if needed) as appropriate. A P value of less than 0.05 was considered significant.
| Results|| |
Twenty-nine male patients having chronic liver disease with cirrhosis scheduled for elective inguinal hernia repair were enrolled in the study. Patient characteristics and clinical features are shown in [Table 1].
Platelet replacements were performed in only three patients whose platelet counts were less than or equal to 50 × 10 3 /μl. Preoperative and postoperative laboratory parameters are shown in [Table 2].
With respect to cardiorespiratory parameters, the HR values during surgery were significantly reduced compared with the baseline levels (P < 0.001). During recovery in the PACU, the HR values were comparable with the baseline levels [Figure 2].
MAP values during surgery were significantly reduced compared with the baseline levels (P < 0.001) [Figure 3].
Respiratory rate values were comparable with the baseline values [Figure 4]. All patients maintained clinically normal SpO 2 . Sedation causing respiratory depression and a SpO 2 less than or equal to 92% was not encountered [Figure 5].
No patients necessitated the conversion to GA and only three patients (10%) needed LA infiltration [Table 3]. Patients had a significantly low VAS for pain in the first 6 h postoperatively [Figure 6].
Mean duration of postoperative analgesia was 13.16±4.5 h. No patients (0%) required rescue analgesia in the first 6 h postoperatively, whereas 16 patients (55.17%) required rescue analgesic during the next following 6 h postoperatively and 11 patients (37.9%) required rescue analgesia between the 18 and 24 h postoperatively. Rescue analgesics for postoperative pain control were administered once in 10 patients (34.5%) and twice in seven patients (24.1%) [Table 3].
Patients reported a high median satisfaction score [Table 4]. The surgical team rated 15 surgeries (51.7%) as excellent, 11 (38%) as good, whereas three operations (10.3%) were rated as poor [Table 4].
Four patients had an incidence of nausea and one patient had an incidence of vomiting, all of which necessitated the administration of intravenous antiemetic, granisetron [Table 5].
| Discussion|| |
Patients with compromised liver function are known to decompensate because of the stress of both anesthesia and surgery, and, despite significant advances in surgical and intensive care, perioperative mortality and morbidity continue to remain high. Mortality is the consequence of a high rate of postoperative decompensation of cirrhosis .
These patients are more likely to have hepatic decompensation with the use of anesthesia. GA reduces total hepatic blood flow, especially because of the contribution of the hepatic artery. Patients with liver disease tend to have several baseline cardiovascular abnormalities, including decreased systemic vascular resistance and increased cardiac index, which may further affect hepatic blood flow. In addition, catecholamine and other neurohormonal responses are impaired; therefore, intraoperative hypotension may not trigger adequate compensatory mechanisms. Anesthetics causing sympathetic blockade further blunt this response. The result of this reduction in hepatic perfusion is a drastic loss of their remaining marginal hepatic function . Therefore, the goals of intraoperative management should involve maintenance of adequate hepatic blood flow and oxygen delivery.
Coagulation defects in liver cirrhosis arise from thrombocytopenia, platelet dysfunction, and decreased levels of circulating clotting factors. The use of neuroaxial blocks has proven effective in the postoperative care of these high-risk patients. However, the possibility of a bloody tap from needle or catheter placement or continuing trauma because of the presence of an epidural catheter has been widely described and may occasionally result in spinal bleeding . Thus, it should not be considered in cirrhotic patients having some form of coagulopathy; in addition, epidural varices can pose an additional risk .
Local infiltration anesthesia or regional block is the most suitable technique in high-risk patients and patients with ASA II-IV scores. However, their use for inguinal hernia repair in patients with cirrhosis accompanied by ascites has some limitations. Parietal nerves infiltration is usually performed blindly on the basis of the click or loss of resistance perceived when the needle passes through the fascia of the external and internal oblique muscles, but this is not the case in these patients. Protein-calorie malnutrition leading to abdominal wall muscle wasting and altered anatomic landmarks may easily cause perforation of the bowels and creation of pelvic hematoma ,,,. In addition, infiltration of LAs into the neck of the hernia sac can lead to tear of the hernial sac and leakage of ascites, as the hernial sac is very thin and easily torn in patients with cirrhosis accompanied by ascites .
Ultrasound-guided nerve block allows to precisely visualize the three muscle layers, the peritoneum, and the intraperitoneal visceral structures, and also allows the real-time assessment of the LA distribution characterized by an anechoic image below the aponeurosis of the internal oblique and transverses abdominis muscles .
There are limited data regarding the applications of TAP blocks instead of GA. When compared with the neuroaxial techniques, TAP blocks do not provide effective surgical anesthesia for intraabdominal manipulation. However, when compared with neuroaxial techniques, TAP block can potentially be used in patients with altered coagulation function and in those who may not tolerate the hemodynamic consequences of the sympathectomy .
This study provided effective intraoperative anesthesia following combined ultrasound-guided ILIH and epsilateral TAP block.
Andersen et al.  and Ding and White  found that the additional use of a preoperative ilioinguinal field block with the well-established stepwise local infiltration anesthesia procedure for inguinal hernia repair improved intraoperative and postoperative pain relief.
In cirrhotic liver patients, avoidance of nephrotoxic drugs - mainly nonsteroidal anti-inflammatory drugs - and early mobilization have proven to be very important in the short-term outcome of these patients. However, early mobilization is difficult with severe pain. Postoperative analgesia in this population remains a challenge, mainly because of the small range between the analgesic effect and the side effects (limited therapeutic index) of conventional opioid intravenous analgesia in patients who have altered multiple neurotransmitter systems, such as gamma-aminobutyric acid (GABAergic) glutamatergic, opioidergic, and so on . Experimental studies have shown that opioidergic neurotransmission (such as μ and δ receptors) may be altered in cirrhotic patients, selectively increasing receptor affinity for opioids. The exogenous or endogenous stimulation of these receptors may lead to impaired mental function and may precipitate episodes of encephalopathy .
Neuroaxial analgesia is effective in postoperative pain relief by targeting the dorsal root and dorsal horn neurons and may modify some deleterious effects of the stress response . The benefits of postoperative pain relief are specifically directed at an improvement of the bowel function and early mobilization . However, these patients may have alterations in coagulation. In this situation, the continuing trauma associated with the presence of an epidural catheter, as well as its removal, could be associated with a serious risk for spinal hematoma .
The results of our study showed that combined ILIH and ipsilateral TAP block lengthen pain relief significantly and reduce the need for complementary analgesia together with early ambulation. Aveline et al.  showed that ultrasound-guided TAP block provided better pain control than 'blind' ilioinguinal nerve block after inguinal hernia repair.
Patient satisfaction regarding intraoperative anesthesia and postoperative analgesia is a complex issue. Satisfaction ratings are often related to the psychosocial aspects of care, such as communication, rather than the technical aspects. In this study, patients reported a high satisfaction score, which may be most likely related first to inexperience of pain intraoperatively (only three patients (10%) had experienced discomfort, which necessitated an additional LA infiltration) and to postoperative analgesia especially the first 6 h when none of the patients complained of pain, and this may have encouraged early ambulation. The surgical team also rated a high satisfaction score, which was contributed to effective intraoperative anesthesia, postoperative analgesia with enhanced early patient ambulation, and patients' satisfaction.
| Conclusion|| |
This study has provided some preliminary indication of the feasibility of combined ultrasound-guided transverse abdominis plane and ILIH nerve block for inguinal hernia repair in patients with liver cirrhosis and is certainly supportive of wider evaluation.
| Acknowledgements|| |
Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]