Original ContributionUltrasound-assisted transversus abdominis plane block vs wound infiltration in pediatric patient with inguinal hernia: randomized controlled trial☆,☆☆,★,★★
Introduction
Inguinal hernia is one of the most common reasons of outpatient pediatric surgery with a rate of 3% and increases up to 10% in premature infants [1]. Effective and safe pain management causes fewer side effects and enables faster hospital discharge. It is also important in overcoming chronic pain in the late postoperative period [2]. The chronic pain which generally seen in postoperative hernia surgery is important problem. An inadequate pain management in early postoperative period and pain intensity may be the reasons of chronic pain. Different methods of analgesia may be used for the treatment of postoperative pain, but use of systemic analgesics may be responsible for the problems as increased rate of side effects and the unpredictable bioavailability of the oral drugs. Wound infiltration is common practice during inguinal area surgery.
Transversus abdominis plane (TAP) block which is one of the abdominal wall blocks is another alternative to reduce the pain. It was described by Rafi [3] in 2001 with blind technique in adult patients; the procedure provides analgesia blocking the anterior branches of the spinal nerves innerving anterior abdominal wall between thoracic 7 and 12 and lumbar 1 levels. Practice of TAP block with blind technique in pediatric patients is not safe because the fascias are weak in children and transition cannot be felt. First intervention with ultrasound in adult patients was practiced by Hebbard et al in 2007 and by Frederickson et al in 2008 in pediatrics [4], [5]. After 3 layers of muscles in anterolateral abdominal wall was visualized with the ultrasound, local anesthetic solution was injected to the neurofascial space between internal oblique and transversus abdominis muscles, and validation was achieved with observing separation of the 2 muscle layers. Hebbard et al [4] first described the technique where needle is inserted through the midaxillary line with medial approach; then they have also described subcostal approach technique. Suresh and Chan [6] described a technique in children where they suggested that, first, rectus muscle must be identified in the lateral of the umbilicus, and then by sliding the probe to the lateral, the TAP area (of the 3 muscles) can be seen easily.
Transversus abdominis plane block was started to be practiced in surgeries in various age groups even infants, but studies on its efficacy are few and the results are different in children [6], [7].
The aim of this study is to compare the analgesic efficacy of ultrasound-guided TAP block and wound infiltration during the first postoperative 24 hours.
Section snippets
Materials and methods
After getting ethical committee approval (83045809/18227) and parent consent, the prospective, observer-blinded clinical study was completed in the pediatric surgery operation theater of I.U. Cerrahpasa Medical School, Anesthesiology and Reanimation Department. Eighty-six American Society of Anesthesiologists (ASA) physical status I to II patients between 6 and 8 years old who planned to undergo unilateral inguinal surgery were included to the study. Patients with history of allergy,
Results
Eighty-six patients were included to the study; 6 of the patients were not eligible, and they were excluded from the study (Fig. 1). No significant difference was observed between groups in terms sex, age, weight, and ASA status (Table 1).
In TAP group, postoperative 5-minute and 1-, 2-, 3-, 6-, 12-, and 24-hour VAS scores were lower compared to INF group (P < .001; Fig. 2). In the pain evaluation, the number of patients with analgesic consumption was significantly higher at the 5th minute and
Discussion
In this study, we stated that Ultrasound (USG)-assisted TAP block delivers a better analgesia in the postoperative period in inguinal hernia surgery compared to wound infiltration.
Transversus abdominis plane block, which is an anterior abdominal wall compartment block, provides analgesia for parietal peritoneum, and its efficacy changes according to the location of the intervention. It was reported that subcostal approach for upper abdominal surgery and posterior approach for lower abdominal
Acknowledgments
The authors would like to thank the surgeons with whom they work together, for their cooperation in performing wound infiltration.
References (14)
- et al.
A systematic review and meta-analysis of caudal blockade versus alternative analgesic strategies for pediatric inguinal hernia repair
J Pediatr Surg
(2013) - et al.
A case of liver trauma with a blunt regional anesthesia needle while performing transversus abdominis plane block
Reg Anesth Pain Med
(2008) - et al.
Chronic pain after childhood groin hernia repair
J Pediatr Surg
(2007) Abdominal field block: a new approach via the lumbar triangle
Anesthesia
(2001)- et al.
Ultrasound-guided transversus abdominis plane block
Anaesth Intensive Care
(2007) - et al.
Early experience with the transversus abdominis plane block in children
Paediatr Anaesth
(2008) - et al.
Ultrasound guided transversus abdominis plane block in infants, children and adolescents: a simple procedural guidance for their performance
Paediatr Anaesth
(2009)
Cited by (27)
Comparison of Analgesic Efficacy of Local Anesthetic Infiltration and Ultrasound-guided Abdominal Wall Nerve Block in Children Undergoing Ambulatory Inguinal Hernia Repair
2022, Journal of Perianesthesia NursingCitation Excerpt :The evidence on the advantage of TAPB over LAI remains inconclusive and is rarely discussed during the intraoperative period.9-15 Both Kendigelen et al.11 and Sahin et al.15 found that in pediatric patients following inguinal hernia surgery, TAPB was associated with lower postoperative pain scores and opioid consumption compared with LAI. Sandeman et al.12 concluded that TAPB conferred no advantage over LAI to pediatric patients after laparoscopic appendectomy.
Perioperative opioid use in paediatric inguinal hernia patients: A systematic review and retrospective audit of practice
2022, Journal of Pediatric SurgeryCitation Excerpt :Prescribed doses varied between surgeons and increasing patient age was associated with an increasing likelihood of opioid prescription. Recording of adverse events was reported in 11/15 studies [18,19,21–28,31]. Most studies mentioned vomiting in 1.6–33.3% of patients [18,21,22,24,26–28], nausea in 11–47.5% of patients [21,26,28] and somnolence in 33–55.6% of patients [21,22].
Erector Spinae Plane Block vs Quadratus Lumborum Block for pediatric lower abdominal surgery: A double blinded, prospective, and randomized trial
2019, Journal of Clinical AnesthesiaCitation Excerpt :Every technique has its own advantages and limitations. The TAP block has become popular due to its ease of application, and the QLB due to its superior analgesia [4,17]. The main problem with the TAP block is that different techniques have resulted in different analgesic outcomes [18].
Ultrasound-Guided Regional Anesthesia
2019, A Practice of Anesthesia for Infants and ChildrenOpioid sparing effect of Erector Spinae Plane block for pediatric bilateral inguinal hernia surgeries
2018, Journal of Clinical Anesthesia
- ☆
Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the ethics committee of Istanbul University Cerrahpasa Faculty of Medicine and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
- ☆☆
Informed consent: Informed consent was obtained from all individual participants included in the study.
- ★
Conflict of interest: The authors declare that they have no conflict of interest.
- ★★
Financial disclosure: The authors declared that this study has received no financial support.