Regional anaesthetic techniques are infrequently used for high-risk thoraco-abdominal surgery. However, Piccioni et al. successfully achieved surgical anaesthesia administering thoracic paravertebral blocks in two patients undergoing thoracoscopy with lorazepam as the sole adjuvant . Transversus abdominis plane (TAP) blocks provide effective postoperative pain management following abdominal surgery [2-4], but the efficacy of TAP blocks for surgical anaesthesia still awaits evaluation. We present a case of ultrasound-guided bilateral dual TAP block that provided adequate surgical anaesthesia.
A 76-year-old woman of ASA physical status 4 was scheduled for revision of abdominal wall defects following emergency laparotomy. Multiple comorbidities included diabetes mellitus, severe left ventricular failure, ischaemic heart disease, chronic renal failure, obesity, arthritis, depression and chronic lung disease. Her initial laparotomy was complicated by pulmonary oedema, cardiac arrhythmias and opioid intoxication. After recovery, a midline deficiency exuding large volumes of fluid necessitated emergency revision surgery.
We decided that a peripheral nerve block technique was indicated . Using an ultrasound-guided four-point injection technique, administering a total of 40 ml lidocaine 1% with adrenaline, the patient reported full anterior abdominal wall dermatomal anaesthesia (T6-12) 10 min following injection. Surgery proceeded uneventfully without discomfort with intravenous midazolam 2 mg, and the patient remained fully awake, spontaneously breathing supplementary oxygen via a facemask. The abdominal wall was completely flaccid, and wound extension and debridement with curettage proceeded uneventfully, with a large sponge and vacuum system placed within the cavity (Fig. 2). The patient was discharged from recovery pain-free, 1 h later.
We believe this is the first peer-reviewed case report on surgical anaesthesia of the abdominal wall using a bilateral dual TAP block. A recent report described a high-risk patient undergoing surgery for a strangulated para-umbilical hernia using bilateral subcostal TAP blocks as the sole anaesthetic, but noted subjective pain, unpleasantness and nausea during bowel palpation, possibly relating to vagal stimulation .
We conclude that surgical anaesthesia requires optimal patient communication, patient acceptance, and complete abdominal wall motor and sensory blockade. Bilateral dual TAP blocks may facilitate surgical anaesthesia of both the abdominal wall and the parietal peritoneum by anaesthetising the thoracolumbar nerves, but visceral stimulation of the coeliac plexus may still challenge intra-abdominal surgical success. Nevertheless, we propose that bilateral dual TAP block is a safe option that expands our anaesthetic repertoire in high-risk patients undergoing abdominal surgery.