We were delighted to read the article by Dr. Zhong et al. in this month’s edition of Plastic and Reconstructive Surgery. A randomized controlled trial looking at the efficacy of transversus abdominis plane blocks used for microsurgical abdominal tissue breast reconstruction has been long-awaited and we read their results with interest.
Zhong et al.1 report their randomized controlled trial comparing a saline control with use of bupivacaine delivered to the transversus abdominis plane by an indwelling catheter placed at the time of surgery. Their technique involves making a 3-cm incision in the triangle of Petit and placing a catheter in the transversus abdominis plane under direct vision.2 They reported significantly reduced use of morphine on postoperative day 1 in the group receiving bupivacaine transversus abdominis plane block.
Hivelin et al.3 described a modified technique for intraoperative, surgeon-delivered bupivacaine transversus abdominis plane block under ultrasound guidance. They advocate use of an ultrasound probe applied directly onto the abdominal fascia before closure of the abdominal defect. The absence of overlying abdominal fat allows for clearer delineation of the layers of abdominal musculature, and allows for a shallower angle for needle entry and constant visualization of the blunt needle tip, thus decreasing risk of perforation of the peritoneum and underlying structures. In their prospective cohort study, they showed significantly less interval and cumulative morphine use in the first 48 hours postoperatively and had no complications.
In the recently published United Kingdom series, Wheble et al.,4 using a similar surgeon-delivered, ultrasound-guided technique as that described by Nash et al.,5 showed similar results with significantly lower morphine use postoperatively, and significantly shorter hospital stay and fewer episodes of postoperative nausea and vomiting. They found this technique to be safe, quick, and cost-effective.
Although both United Kingdom and French articles were cohort studies, we feel that the use of a single-dose transversus abdominis plane block compared with catheter infusion warrants further investigation. Continuous infusion by means of intraoperatively placed transversus abdominis plane catheters has been shown to decrease postoperative opioid use; however, we wonder whether single-dose, ultrasound-guided transversus abdominis plane block confers a similar benefit and is more cost-effective and with fewer potential complications.
The authors have no commercial associations or financial interest in any of the products, devices, or drugs mentioned in this communication. No funding was received for this submission.
George A. C. Wheble, M.R.C.S.
Department of Burns, Plastic and Reconstructive Surgery
Stoke Mandeville Hospital
Aylesbury, United Kingdom
Eric K. H. Tan, M.R.C.S.
Department of Plastic Surgery
John Radcliffe Hospital
Oxford, United Kingdom
Matthew Turner, M.A., F.R.C.A.
Department of Anesthesia
Queen Alexandra Hospital
Charles A. T. Durrant, M.A., F.R.C.S.(Plast.)
Simon Heppell, F.R.C.S.Ed.(Plast.)
Mountbatten Department of Plastic and
Queen Alexandra Hospital
Portsmouth, United Kingdom
1. Zhong T, Ojha M, Bagher S, et al. Transversus abdominis plane block reduces morphine consumption in the early postoperative period following microsurgical abdominal tissue breast reconstruction: A double-blind, placebo-controlled, randomized trial. Plast Reconstr Surg. 2014;134:870–878
2. Zhong T, Wong KW, Cheng H, et al. Transversus abdominis plane (TAP) catheters inserted under direct vision in the donor site following free DIEP and MS-TRAM breast reconstruction: A prospective cohort study of 45 patients. J Plast Reconstr Aesthet Surg. 2013;66:329–336
3. Hivelin M, Wyniecki A, Plaud B, Marty J, Lantieri L.. Ultrasound-guided bilateral transversus abdominis plane block for postoperative analgesia after breast reconstruction by DIEP flap. Plast Reconstr Surg. 2011;128:44–55
4. Wheble GA, Tan EK, Turner M, Durrant CA, Heppell S.. Surgeon-administered, intra-operative transversus abdominis plane block in autologous breast reconstruction: A UK hospital experience. J Plast Reconstr Aesthet Surg. 2013;66:1665–1670
5. Nash H, Khoda B, Heppell S, Turner M.. TAP blocks in breast reconstructions using abdominal wall tissue. Anaesthesia. 2011;66:750–751
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