Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 2  |  Page : 280-283

Transversus abdominis plane block versus local anesthetic wound infiltration in patients undergoing open inguinal hernia repair surgery


Department of Anesthesia and ICU, Faculty of Medicine, Benha University, Benha, Egypt

Date of Submission14-Aug-2015
Date of Acceptance29-Oct-2015
Date of Web Publication11-May-2016

Correspondence Address:
Ahmed M Abd El-Hamid
Department of Anesthesia and ICU, Faculty of Medicine, Benha University, 20 Ezz Eldin Omar St., Elharam, Giza, 12111
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.182269

Rights and Permissions
  Abstract 

Objectives
This study aimed to compare the analgesic effect of ultrasound-guided transversus abdominis plane (TAP) block versus wound infiltration in patients undergoing open inguinal hernia repair.
Patients and methods
A total of 60 male patients scheduled for open unilateral inguinal hernia repair under general anesthesia were randomly allocated into two equal groups: group W received wound infiltration with 0.2 ml/kg of 0.25% levobupivacaine at the site of incision, and group T received ultrasound-guided TAP block with 0.5 ml/kg of 0.25% levobupivacaine. Time to first analgesic request, total morphine requirement over 24 h, and visual analogue pain score at rest and during cough were assessed over the course of 24 h.
Results
Total morphine requirement during the first 24 h was significantly less in group T. A total of 21 patients in group W required supplemental morphine compared with 13 patients in group T. Time to first analgesic request was significantly longer in group T. Patients receiving TAP block had significantly lower pain scores at rest for 12 h and on cough for 6 h after operation when compared with patients who received wound infiltration.
Conclusion
TAP block provided more reliable and effective analgesia and less total 24-h postoperative morphine consumption compared with wound infiltration with the local anesthetic.

Keywords: local wound infiltration, open inguinal hernia repair, transversus abdominis plane block


How to cite this article:
Abd El-Hamid AM, Afifi EE. Transversus abdominis plane block versus local anesthetic wound infiltration in patients undergoing open inguinal hernia repair surgery. Ain-Shams J Anaesthesiol 2016;9:280-3

How to cite this URL:
Abd El-Hamid AM, Afifi EE. Transversus abdominis plane block versus local anesthetic wound infiltration in patients undergoing open inguinal hernia repair surgery. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2021 Oct 25];9:280-3. Available from: http://www.asja.eg.net/text.asp?2016/9/2/280/182269


  Introduction Top


Postoperative pain management is of great importance in perioperative anesthetic care [1]. The transversus abdominis plane (TAP) block is a regional anesthesia technique that provides analgesia to the parietal peritoneum as well as the skin and muscles of the anterior abdominal wall [2]. It has been shown to be a safe and effective postoperative adjunct analgesia method in a variety of surgical procedures and it is suggested as part of the multimodal anesthetic approach to enhance recovery after lower abdominal surgeries [3]. Randomized controlled trials have demonstrated the efficacy of TAP block in providing postoperative analgesia for up to 24 h after lower abdominal surgery [4].

Local anesthetic wound infiltration is also a commonly used method for reducing postoperative pain. Postoperative pain relief can be obtained by means of single injection of local anesthesia into the skin and subcutaneous tissue layer at surgical incision sites, which could decrease the pain scores postoperatively [5].

The aim of this study was to compare the analgesic effect of ultrasound-guided TAP block versus wound infiltration in patients undergoing open inguinal hernia repair.


  Patients and methods Top


This study was conducted in Benha University Hospitals from April 2014 to March 2015. After local ethical committee approval and patient's informed written consent, this prospective randomized comparative clinical trial was conducted on 60 male patients of ASA physical status I and II scheduled for open unilateral inguinal hernia repair under general anesthesia. Patients were allocated randomly using sealed envelopes, according to a computer-generated sequence of random numbers, into two equal groups.

Group W received wound infiltration with 0.2 ml/kg of 0.25% levobupivacaine at the site of incision after induction of general anesthesia and before start of surgical procedure.

Group T received ultrasound-guided TAP block with 0.5 ml/kg of 0.25% levobupivacaine on the same side as the hernia after induction of general anesthesia and before start of surgical procedure.

Exclusion criteria were as follows: inability to consent to the study; skin infection at the puncture site; chest diseases; hepatic, renal, or coagulation disorders; or contraindication to any of the drugs used during the study.

One hour before surgery after insertion of venous access, all patients received premedication in the form of 0.05-0.1 mg/kg of midazolam. Perioperative monitoring included ECG, pulse oximetry, noninvasive arterial blood pressure, capnography, and temperature monitoring. General anesthesia was induced using 1.5-2.5 mg/kg of propofol, 0.5 mg/kg of atracurium to facilitate endotracheal intubation, and 2 mg/kg of fentanyl. Anesthesia was maintained using isoflurane (1 MAC), and atracurium supplements were given every 20 min to maintain muscle relaxation.

TAP block was performed under ultrasound guidance using SonoSite M Turbo (SonoSite, USA) with linear multifrequency 6-13 MHz transducer (L25 × 13-6 MHz linear array) scanning probe. Under complete aseptic condition and with the patient in the supine position, the TAP block was performed laterally behind the midaxillary line between the iliac crest and the subcostal margin. The plane between the internal oblique and transversus abdominis muscle was located around the midaxillary line with the probe transverse to the abdomen. Anteriorly, the needle (Stimuplex D needles; B. Braun, Melsungen, Germany) was passed to come perpendicular to the ultrasound beam and placed between transversus and internal oblique posterior to the midaxillary line. Thereafter, the local anesthetic was injected.

At the end of surgical procedure, anesthesia was discontinued and muscle relaxant reversed using 0.05 mg/kg of neostigmine and 0.02 mg/kg of atropine. Thereafter, patients were extubated and transferred to the postanesthesia care unit. An independent anesthesiologist conducted postoperative assessments and was not aware of group allocation. Rescue analgesia was given with morphine 3 mg intravenous boluses on demand, or whenever visual analogue scale (VAS) pain score was 4 or greater.

The duration of surgery (the time from skin incision until the removal of surgical drapes), time to first analgesic request (the time from patient's arrival to the postanesthesia care unit until a VAS>4), total morphine requirement over 24 h, number of patients requiring analgesia, and visual analogue pain score (at rest and during cough) at 2, 4, 8, 12, and 24 h were assessed over the course of 24 h.

Statistical analysis

  1. Data were analyzed using SPSS (version 16; SPSS Inc., Chicago, Illinois, USA).
  2. Quantitative data were presented as a mean and SD and were analyzed using Student's t-test.
  3. Qualitative data were presented as number and percentages and were analyzed using the c2 and Z tests.
  4. Visual analogue score was presented as median and interquartile range and was analyzed using the Mann-Whitney U-test.
  5. A P-value less than 0.05 was considered statistically significant, and a P-value less than 0.01 was considered statistically highly significant.
  6. Sample size was calculated according to a pilot study from the first eight patients at a error 0.05 and 80% power. Assuming 30% decrease in the total morphine consumption, the calculated effect size was 0.709. Thirty patients were required for each group.

  Results Top


A total of 80 patients were screened during the study period. Of them, 11 patients did not match the inclusion criteria, five patients refused to participate, and one patient was excluded as he had bronchial asthma. A total of 63 patients were included in the study, but three more patients were excluded shortly thereafter because two patients were discharged before 24 h and one patient developed postoperative chest pains. Thus, 60 patients completed the study protocol [Figure 1].
Figure 1: Consort flow diagram

Click here to view


All patients were similar with respect to patient demographic characteristics, ASA physical status, and duration of surgery [Table 1].
Table 1 Demographic characteristics and clinical features

Click here to view


Total morphine requirement during the first 24 h was significantly less in group T compared with group W. A total of 21 patients in group W required supplemental morphine, whereas only 13 patients in group T required supplemental morphine. Time to first analgesic request was significantly longer in group T than in group W [Table 1].

Patients receiving TAP block had significantly lower pain scores at rest for 12 h and on cough for 6 h after operation compared with patients who received wound infiltration [Table 2] and [Table 3].
Table 2 Visual analogue scale at rest

Click here to view
Table 3 Visual analogue scale during cough

Click here to view



  Discussion Top


Postoperative analgesia is one of the main concerns of both the surgeons and the patients. Multiple methods have been put into use to achieve this goal, such as local anesthetic infiltration, epidural analgesia, peripheral nerve block, and patient-controlled analgesia [2].

Several studies have documented that TAP block provided effective postoperative analgesia during the first 24 h following lower abdominal surgical procedures [6-9].

VAS pain score, considered the gold standard of pain quantification, was used to evaluate the severity of postoperative pain at rest and during cough.

The present study found that there was a significantly lower pain score in the TAP group at 12 h postoperatively compared with the wound infiltration group. Total morphine consumption was less in the TAP group. The number of patients who required supplemental morphine was less in TAP block. Time to first analgesic request was longer in the TAP group. This is consistent with the results of Sivapurapu et al. [10], who compared the analgesic efficacy of TAP block with that of direct infiltration of local anesthetic into surgical incision in lower abdominal gynecological procedures under general anesthesia. Time to rescue analgesic was significantly longer and the VAS scores were lower in the TAP group. The 24 h morphine requirement and the incidence of side effects were less in the TAP group. In a meta-analysis conducted by Mishriky et al. [11], they reported that TAP block significantly reduced opioid consumption and reduced pain scores for up to 12 h postoperatively.

In a prospective, randomized, double-blind study of 64 patients undergoing inguinal hernia repair, Salman et al. [12] found that TAP block provided effective analgesia, reducing total 24-h postoperative analgesic consumption and morphine requirement.


  Conclusion Top


We conclude that ultrasound-guided TAP block provided more reliable and effective analgesia and lower total 24-h postoperative morphine consumption compared with local anesthetic wound infiltration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Schug SA. 2011 - the global year against acute pain. Anaesth Intensive Care 2011; 39:11-14.  Back to cited text no. 1
    
2.
Yu N, Long X, Lujan-Hernandez JR, Succar J, Xin X, Wang X. Transversus abdominis-plane block versus local anesthetic wound infiltration in lower abdominal surgery: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol 2014; 14:121.  Back to cited text no. 2
    
3.
Young MJ, Gorlin AW, Modest VE, Quraishi SA. Clinical implications of the transversus abdominis plane block in adults. Anesthesiol Res Pract 2012; 2012: 731645,   Back to cited text no. 3
    
4.
Al-Sadek WM, Rizk SN, Selim MA. Ultrasound guided transversus abdominis plane block in pediatric patients undergoing laparoscopic surgery. Egypt J Anaesthesia 2014; 30:273-278.  Back to cited text no. 4
    
5.
Coughlin SM, Karanicolas PJ, Emmerton-Coughlin HM, Kanbur B, Kanbur S, Colquhoun PH. Better late than never? Impact of local analgesia timing on postoperative pain in laparoscopic surgery: a systematic review and meta-analysis. Surg Endosc 2010; 24:3167-3176.  Back to cited text no. 5
    
6.
McDonnell JG, O'Donnell B, Curley G, Heffernan A, Power C, Laffey JG. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. Anesth Analg 2007; 104:193-197.  Back to cited text no. 6
    
7.
McDonnell JG, O'Donnell BD, Farrell T, Gough N, Tuite D, Power C, Laffey JG. Transversus abdominis plane block: a cadaveric and radiological evaluation. Reg Anesth Pain Med 2007; 32:399-404.  Back to cited text no. 7
    
8.
El-Dawlatly AA, Turkistani A, Kettner SC, Machata AM, Delvi MB, Thallaj A, et al. Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br J Anaesth 2009; 102:763-767.  Back to cited text no. 8
    
9.
Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain 2005; 114:29-36.  Back to cited text no. 9
    
10.
Sivapurapu V, Vasudevan A, Gupta S, Badhe AS. Comparison of analgesic efficacy of transversus abdominis plane block with direct infiltration of local anesthetic into surgical incision in lower abdominal gynecological surgeries. J Anaesthesiol Clin Pharmacol. 2013; 29:71-75.  Back to cited text no. 10
    
11.
Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after cesarean delivery: a systematic review and meta-analysis. Can J Anaesth 2012; 59:766-778.  Back to cited text no. 11
    
12.
Salman AE, Yetiºir F Yürekli B, Aksoy M, Yildirim M, Kiliç M. The efficacy of the semi-blind approach of transversus abdominis plane block on postoperative analgesia in patients undergoing inguinal hernia repair: a prospective randomized double-blind study. Local Reg Anesth 2013; 6:1-7.  Back to cited text no. 12
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


This article has been cited by
1 Comparing the analgesic efficacy of transversus abdominis plane block versus wound infiltration for post cesarean section pain management: A prospective cohort study
Wudie Mekonnen Alemu,Henos Enyew Ashagrie,Abatneh Feleke Agegnehu,Biruk Adie Admass
International Journal of Surgery Open. 2021; : 100377
[Pubmed] | [DOI]
2 Effect of Transverses Abdominis Block and Subcutaneous Wound Infiltration on Post-Operative Pain Analgesia after Cesarean Section at (“XXXX”, XXXX) A Prospective Cohort Study
Million Habtemariam,Hailemariam Muluget,Fisthum Solomon,Sleshi Hailu,Nugusu Ayalew,Zemedu Aweke
International Journal of Surgery Open. 2020;
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Patients and methods
  Results
  Discussion
  Conclusion
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed2462    
    Printed74    
    Emailed0    
    PDF Downloaded269    
    Comments [Add]    
    Cited by others 2    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]