Regional for inguinal hernia

[cchoukal]

---

Members do not see this ad.

Patient for tomorrow is 74 and has the routine VA-related health problems (GERD, HTN, DM, et al), for R inguinal hernia.

Pre-op note (I haven't seen him myself) says he refuses spinal d/t "back problems," and doesn't want GA because of some urinary retention he had after a previous shoulder scope. He apparently "strongly prefers" MAC and local. Of course, his surgeon is one who wants all his hernias intubated an paralyzed, but that's another matter.

I've done a handful of USG TAP blocks for other procedures, but never for inguinal hernia. My (naive) question is whether this is adequate or whether everyone's doing these with ilioinguinal/iliohypogastric blocks.

Thanks.

 

[imfrankie]

Patient for tomorrow is 74 and has the routine VA-related health problems (GERD, HTN, DM, et al), for R inguinal hernia.

Pre-op note (I haven't seen him myself) says he refuses spinal d/t "back problems," and doesn't want GA because of some urinary retention he had after a previous shoulder scope. He apparently "strongly prefers" MAC and local. Of course, his surgeon is one who wants all his hernias intubated an paralyzed, but that's another matter.

I've done a handful of USG TAP blocks for other procedures, but never for inguinal hernia. My (naive) question is whether this is adequate or whether everyone's doing these with ilioinguinal/iliohypogastric blocks.

Thanks.

Not to answer the question, but the primo block for this operation is T10 - L1 PVBs.

 

[dhb]

TAP, ilioinguinal/iliohypogastric, local, it's all good as long as the patient and surgeon are on the same page which seems not to be the case here.

 

[Oggg]

Refer the pt to the surgeon. Let the surgeon convince the pt to get GA, or to let him have mac/local. TAP block 30+minutes prior to incision, still need local infiltration for visceral component.

 

[jwk]

TAP, ilioinguinal/iliohypogastric, local, it's all good as long as the patient and surgeon are on the same page which seems not to be the case here.

We used to have one surgeon that insisted on MAC + local and he did his own ilioinguinal blocks under semi-direct vision after his incision and early dissection. Worked great.

 

[dhb]

We used to have one surgeon that insisted on MAC + local and he did his own ilioinguinal blocks under semi-direct vision after his incision and early dissection. Worked great.

Big series from Scandinavia showed local was "safer" (less adverse events) than spinal or GA

 

[Bertelman]

We used to have one surgeon that insisted on MAC + local and he did his own ilioinguinal blocks under semi-direct vision after his incision and early dissection. Worked great.

I'm guessing he didn't work at the VA.

+1 for the paravertebral.

 

[BLADEMDA]

Patient for tomorrow is 74 and has the routine VA-related health problems (GERD, HTN, DM, et al), for R inguinal hernia.

Pre-op note (I haven't seen him myself) says he refuses spinal d/t "back problems," and doesn't want GA because of some urinary retention he had after a previous shoulder scope. He apparently "strongly prefers" MAC and local. Of course, his surgeon is one who wants all his hernias intubated an paralyzed, but that's another matter.

I've done a handful of USG TAP blocks for other procedures, but never for inguinal hernia. My (naive) question is whether this is adequate or whether everyone's doing these with ilioinguinal/iliohypogastric blocks.

Thanks.

TAP block plus local infiltration in the wound. In addition, premed for GERD and plan on TIVA with TAP. I use propofol plus a little fentanyl. If EF is below 30 percent then consider low dose propofol drip with ketamine (works great).

My TAP blocks for this procedure works well and most studies show TAP superior to surgical blind field blocks. Still, I request surgeon to infiltrate wound for visceral component.

Another approach is simply local field block by surgeon, wound infiltration with local and propofol drip. This combo works fine and my group has performed several thousand this way.

 

[BLADEMDA]

Br J Anaesth. 2011 Mar;106(3):380-6. doi: 10.1093/bja/aeq363. Epub 2010 Dec 21.
Comparison between ultrasound-guided transversus abdominis plane and conventional ilioinguinal/iliohypogastric nerve blocks for day-case open inguinal hernia repair.
Aveline C, Le Hetet H, Le Roux A, Vautier P, Cognet F, Vinet E, Tison C, Bonnet F.
Source
Department of Anaesthetics, Polyclinique Sévigné, 35510 Cesson-Sevigne, France. [email protected]
Abstract
BACKGROUND:
Transversus abdominis plane (TAP) block has been reported to provide effective analgesia after lower abdominal surgery, but there are few data comparing ilioinguinal/iliohypogastric nerve (IHN) block with ultrasound-guided TAP block in patients undergoing inguinal hernia repair.
METHODS:
Two hundred and seventy-three patients undergoing day-case open inguinal hernia repair with a mesh were randomly allocated to receive either ultrasound-guided TAP block or blind IHN block with levobupivacaine 0.5%, before surgery. Patients were monitored for visual analogue scale (VAS) scores at rest (in the post-anaesthesia care unit, and at 4 and 12 h) and at rest and during movement (at 24, 48 h, 3 and 6 months). Pain at 6 months was also assessed using the DN4 questionnaire for neuropathic pain.
RESULTS:
Median VAS pain scores at rest were lower in the ultrasound-guided TAP group at 4 h (11 vs 15, P=0.04), at 12 h (20 vs 30, P=0.0014), and at 24 h (29 vs 33, P=0.013). Pain after the first 24 h, at 3 and 6 months after surgery, and DN4 scores were similar in both groups (P=NS). The proportion of patients with VAS >40 mm on movement at 6 months was comparable {18.2% [95% CI (12.2-26.1%)] vs 22.4% (15.8-30.6%) in the TAP and IHN groups, respectively, P=0.8}. Postoperative morphine requirements were lower during the first 24 h in the TAP block group (P=0.03).
CONCLUSIONS:
Ultrasound-guided TAP block provided better pain control than 'blind' IHN block after inguinal hernia repair but did not prevent the occurrence of chronic pain.

 

[BLADEMDA]

Eur J Anaesthesiol. 2013 Jan 18. [Epub ahead of print]
Ultrasound-guided transversus abdominis plane block in children: A randomised comparison with wound infiltration.
Sahin L, Sahin M, Gul R, Saricicek V, Isikay N.
Source
From the Department of Anesthesiology, Medicine Faculty, Gaziantep University (LS, RG, VS, NI), Department of Anesthesiology, 75 Year Obstetrics and Gynecology Hospital, Gaziantep, Turkey (MS).
Abstract
CONTEXT:
The transversus abdominis plane (TAP) block is a new regional anaesthesia technique applicable to infants and children.
OBJECTIVE(S):
The present study was designed to evaluate the analgesic efficacy of ultrasound-guided TAP block with high volume local anaesthetic (0.5 ml kg) during the first 24 h after surgery in children undergoing inguinal hernia repair.
DESIGN:
Randomised comparative study.
SETTING:
Gaziantep University Hospital between December 2010 and May 2011.
PATIENTS OR OTHER PARTICIPANTS:
Fifty-seven children between 2 and 8 years of age undergoing unilateral inguinal hernia repair were randomised to TAP block (group T, n = 29) or to wound infiltration (group C, n = 28).
INTERVENTION(S):
A TAP block using ultrasound guidance with 0.25% levobupivacaine 0.5 ml kg or wound infiltration with 0.2 ml kg 0.25% levobupivacaine, was performed on the same side as the hernia under general anaesthesia.
MAIN OUTCOME MEASURES:
Time to first analgesic, cumulative number of doses of analgesic, pain scores and adverse effects were assessed over the course of 24 h.
RESULTS:
The time to first analgesic (mean&#8202;±&#8202;SD) was significantly longer in group T than in group C (17&#8202;±&#8202;6.8 vs. 4.7&#8202;±&#8202;1.6&#8202;h, respectively; P&#8202;<&#8202;0.001). Thirteen (45%) patients in group T did not require any analgesic within the first 24&#8202;h. The cumulative number of doses of analgesic was significantly lower in group T than in group C (1.3&#8202;±&#8202;1.2 vs. 3.6&#8202;±&#8202;0.7, respectively, P&#8202;<&#8202;0.001). Pain scores were significantly different between the groups at all time points except at 1, 20 and 24&#8202;h (P&#8202;<&#8202;0.001).
CONCLUSION:
Ultrasound-guided TAP block with high volume (0.5&#8202;ml&#8202;kg) 0.25% levobupivacaine provides prolonged postoperative analgesia and reduced analgesic use without any clinical side-effects after unilateral hernia repair in children.
TRIAL REGISTRATION:
ACTRN12611000585921&#8202;(7/06/2011) from Australian New Zealand Clinical Trials Registry.

 

[TeamZissou]

Attending I'm working with has done a few of them this week for inguinal hernia repairs and seems to have had good success.

http://www.nysora.com/files/uploaded/JNYSORA/Volume12/(v12p28-33)TAPBlock.pdf

 

[Oggg]

Though the papers say local infiltration is not as good as local+TAP, it seems that the hernia pts at my hospital do very well with GA+local. My surgeons aren't enthusiastic about TAP blocks yet, so I've been trying to do TAPs for rescue analgesia. At my place, very few pts need them. I have done maybe two good rescues for hernias. I'm thinking of doing a chart review of all the hernias from last year to see how they did in PACU, but I'm afraid I will show that 0.01% of pts need more than fentanyl 50mcg in PACU after GA + local.

 

[Trisomy13]

Most of my inguinal hernias get a propofol infusion, nitrous and LMA. Localization by the surgeon. Everything off while closing and the patient moves himself to the stretcher. Fully awake by the time they hit recovery, and they get out of there fast. I love regional but for inguinals this is my go-to approach.

 

[BLADEMDA]

Most of my inguinal hernias get a propofol infusion, nitrous and LMA. Localization by the surgeon. Everything off while closing and the patient moves himself to the stretcher. Fully awake by the time they hit recovery, and they get out of there fast. I love regional but for inguinals this is my go-to approach.

At my institution they get Propofol via an infusion and some Fentanyl plus local infiltration by the surgeon. At the end of the case Propofol drip off and patient awake. Next case.

 

[Oggg]

Propofol shortage not affecting anyone?

 

[Outrigger]

Ultrasound guided TAP block plus local infiltration by the surgeon. There's no such thing as a failed block, only too little propofol supplementation. 🙂