The ultrasound (US)-guided transversalis fascia plane block (TFPB) was first described by Hebbard1 in 2009 as a novel technique that may have a role for postoperative analgesia after surgical procedures that involve primarily the area of T12–L1 dermatomes. Inguinal herniorrhaphy is one of the most commonly performed surgical procedures. The inguinal area receives highly variable sensory innervation from ilioinguinal (IIN), iliohypogastric (IHN), and genitofemoral (GFN) nerves.2 Because of the complexity of the inguinal region innervation, the various anatomical landmark-based techniques for achieving target nerves blockade may often not provide a reliable block of all the nerves involved, resulting in insufficient analgesia for inguinal herniorrhaphy.3 Other US-guided techniques described in the literature such as the transversus abdominis plane block (TAPB) and the quadratus lumborum block (QLB) have been shown to provide effective analgesia for surgery involving T12–L1 dermatomes. López-González et al had compared the effectiveness of US-guided TFPB and TAPB for postoperative analgesia in outpatient unilateral inguinal hernia repair. The authors concluded that the 2 techniques were equally effective, but a higher level of sensory block was achieved in the US-guided TFPB group.4 Chin et al5 reported the similarity of the US-guided TFPB and the QLB 1, in terms of approach and anesthetic effectiveness. However, in the US-guided TFPB, the point of injection is more caudal and more anterior. This may result in more localized spread, specifically targeting the IIN and IHN where they run deep to the transversus abdominis muscle (TAM) before ascending into the transversus abdominis plane (TAP).5 Elsharkawy6 reported a reliable dermatomal coverage from T6–7 to L1–2 when using an in-plane US-guided anterior QLB, demonstrating that the dermatomal level of analgesia achieved was variable depending on the approach used. A recent study had compared the spread of bilateral analgesic QLB 1 or US-guided TFPB in 7 patients scheduled for trauma or surgical purposes computed tomography, demonstrating in all cases a predominant spread of contrast media in the retroperitoneal space. The authors concluded that in both QLB 1 and US-guided TFPB, the local anesthetic solution spreads deep to the transversalis fascia within the retroperitoneal, posterior pararenal space.7 Based on these findings, we hypothesized that the US-guided TFPB could provide a reliable block of the nerves T12–L1. We report the use of this technique in a patient undergoing inguinal herniorrhaphy. The patient provided written permission for publication of the report.
The patient was a 50-year-old man, American Society of Anesthesiologists physical status III, scheduled to undergo inguinal herniorrhaphy. His medical history included hypertensive cardiomyopathy, a moderate aortic stenosis, and severe pulmonary fibrosis. With the patient in a supine position, a high-frequency linear US probe (15 MHz) was placed in a transverse orientation above the iliac crest. The external oblique, internal oblique, and TAMs were identified. Then, the transducer was moved posteriorly until the TAM tapers off into its aponeurosis, the thoracolumbar fascia, adjacent to the quadratus lumborum muscle (QLM). Subsequently, a 22-gauge 80-mm needle (SonoTAP, Pajunk, Germany) was advanced using an in-plane technique. After having placed the needle tip in the virtual triangular plane located between the posterior edge of the TAM, the QLM, and the underlying transversalis fascia, 20 mL of 0.5% levobupivacaine was injected. We ultrasonically confirmed the downward displacement of the retroperitoneal fat deep into the transversalis fascia and the spread of local anesthetic over the anterior surface of the QLM (Figure). Intraoperative sedation (score 2 on modified Wilson sedation scale)8 was provided by intravenous propofol infusion (3 mg/kg/h) and 50 µg fentanyl. Oxygen (4 L/min) was administered by Venturi mask, and end-tidal CO2 was monitored. Reliable surgical analgesia and hemodynamic stability were achieved. Neither blood pressure nor heart rate increased during traction of the hernia sac, and no additional local anesthetic was needed. We assessed the duration of the block by testing the area (homolateral abdominal lower quadrant) for the loss of sensation to pinprick, cold, and touch sensation. By this technique, the duration of the sensory block was about 12 hours. Scheduled postoperative analgesia was provided by intravenous acetaminophen 1 g every 8 hours, with intravenous 30 mg ketorolac as rescue medication. Pain intensity was assessed using a numerical rating scale of 0–10. Pain assessment was performed every 3 hours until hospital discharge. Postoperatively the patient reported a good-quality analgesia. During the first 24 hours after surgery, the numerical rating scale pain score was <3. Only 1 g acetaminophen was required. The postoperative period was uneventful.
Inguinal herniorrhaphy is one of the most commonly performed surgical procedures. Moreover, the high incidence of chronic pain after inguinal hernia repair has recently been documented as a significant problem, which may affect the quality of life of patients resulting in high social costs.9 The inguinal area receives highly variable sensory innervation from IIN, IHN, and GFN.2 The IIN and IHN originate from the lumbar plexus and travel across the lower abdomen wall with free communications between their branches before piercing the TAM to course within the TAP.10 Because the IIN and IHN course within the TAP for a short and variable length, the L1 dermatomes may not reliably be blocked during standard US-guided TAPB. Various anatomical landmark-based techniques for achieving IIN and IHN blockade have been widely performed, but they may often lead to an inaccurate placement of local anesthetic resulting in block failure.3 Moreover, US-guided techniques for IIN and IHN blockade may also provide insufficient analgesia because of possible GFN nociceptive afferent inputs during inguinal herniorrhaphy.11 The GFN originates from L1 and L2 as a part of the lumbar plexus and emerges on the anterior surface of the psoas muscle caudally, crossing obliquely behind the ureter and dividing above the inguinal ligament into genital and femoral branches.10 Previous studies suggested that the benefit of adding a GFN block to IIN and IHN blocks is limited to intraoperative attenuation of hemodynamic response to sac traction during open inguinal hernia repair without any postoperative effect.11 However, a recent randomized controlled pilot study including 80 male adults with American Society of Anesthesiologists physical status I–III undergoing elective open herniorrhaphy showed that the combination of GFN and IIN/IHN blocks compared to IIN/IHN blocks alone was associated with lower postoperative visual analog scale scores and lower doses of intraoperative additional local anesthetic.12
Recent dissections of anatomic specimens of human abdominal wall documented that the IIN and IHN run across the anterior surface of the QLM and that the GNF runs on the psoas muscle.13 A recent case report described the occurrence of unanticipated quadriceps and hip flexor weakness after performance of the US-guided TFPB.14 These clinical findings suggested that the lumbar plexus and the transversalis fascia may be anatomically contiguous. Thus, recent evidence suggests that a partial lumbar plexus block may occur as a result of proximal spread of the local anesthetic injected in the transversalis fascia plane to the potential space between the psoas muscle and QLM through the thoracolumbar fascia.14 Previous work by Carney et al15 showed that the embryogenic origin of the QLM and psoas muscle in the thoracic cage and the continuation of the transversalis fascia with the endothoracic fascia at the level of the arcuate ligaments at the diaphragm might explain the potential spread of local anesthetic to the thoracic paravertebral space.
Based on these findings, we hypothesized that the US-guided TFPB could provide a reliable block of the nerves T12–L1, which pass in a virtual anatomical triangular plane located between the TAM and the transversalis fascia anterolateral to the QLM, as suggested by Hebbard1 in his first description. Moreover, our experience suggests that the US-guided TFPB presents a viable alternative to US-guided anterior TAPB and QLB and to general and neuraxial anesthesia. This technique, as part of a multimodal analgesic regimen, may provide good-quality analgesia, reducing opioid requirements and opioid-related side effects in the postoperative period with excellent patient satisfaction. Future prospective studies will be necessary to evaluate the clinical usefulness of US-guided TFPB for inguinal hernia repair and to compare this approach with the other US-guided techniques for IIN, IHN, and GFN blocks and wound infiltration.6 Further studies will also be needed to investigate if US-guided TFPB may play a role in chronic postsurgical pain prevention after inguinal herniorrhaphy.9
The authors gratefully acknowledge Dr.ssa Carla Stecco for their anatomical studies that inspired this case report.
Name: Paolo Scimia, MD.
Contribution: This author helped conceive and design the study.
Name: Erika Basso Ricci, MD.
Contribution: This author helped acquire, analyze, and interpret the data.
Name: Emiliano Petrucci, MD.
Contribution: This author helped acquire the data.
Name: Astrid Ursula Behr, MD.
Contribution: This author helped supervise the study.
Name: Franco Marinangeli, MD.
Contribution: This author helped supervise the study.
Name: Pierfrancesco Fusco, MD.
Contribution: This author helped revise the manuscript.
This manuscript was handled by: Hans-Joachim Priebe, MD, FRCA, FCAI.
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