Korean J Pain.  2021 Apr;34(2):201-209. 10.3344/kjp.2021.34.2.201.

Ultrasound-guided transversalis fascia plane block versus transmuscular quadratus lumborum block for post-operative analgesia in inguinal hernia repair

• Fouad AZ
• Abdel-Aal IRM
• Ali Gadelrab MRM
• Mohammed HMEHS

• KMID: 2514420
• DOI: http://doi.org/10.3344/kjp.2021.34.2.201

Abstract

Background
Inguinal hernia repair is one of the most commonly performed surgical procedures. Regional blocks might provide excellent analgesia and reduce complications in the postoperative period. We aimed to compare the postoperative analgesic effect of the ultrasound-guided transversalis fascia (TF) plane block versus the transmuscular quadratus lumborum (QL) block in patients undergoing unilateral inguinal hernia repair.
Methods
Fifty patients enrolled in this comparative study and were randomly assigned into two equal groups. One group received an ultrasound-guided QL block. In comparison, the other group received an ultrasound-guided TF plane block. The primary outcome was the patient-assessed resting, and movement-induced pain on the numeric pain rating scale (NRS) measured at 30 minutes postoperatively. Secondary outcomes included the percentage of patients receiving rescue analgesia in the first postoperative day, ease of performance of the technique, and incidence of adverse effects.
Results
There were no statistically significant differences in NRS at rest and with movement between the groups over the first 24 hours postoperatively. The proportion of patients that received postoperative rescue analgesics during the first 30 minutes postoperatively was 4% (n = 1) in the QL group compared to 12% (n = 3) in the TF group. However, the mean performance time of the TF block was shorter than that of the QL block, and the performance of the TF block appeared easier technically.
Conclusions
The ultrasound-guided TF plane block could be as effective as the QL block in lowering pain scores and decreasing opioid consumption following nonrecurrent inguinal herniorrhaphy.

Keyword

Analgesia; Analgesics; Opioid; Fascia; Hernia; Inguinal; Herniorrhaphy; Nerve Block; Pain Management; Pain; Postoperative; Ultrasonography; Interventional

Figure

• 

  Fig. 1 Flowchart of the study.

• 

  Fig. 2 Sonoanatomy for QL3 block. QL: quadratus lumborum muscle, PS: psoas major muscle, ES: erector spinae muscle, TP: transverse process.

• 

  Fig. 3 Picture showing spread of local anesthetic injectate in quadratus lumborum muscle (QL) block. Arrow pointing to target for local anesthetic solution deposition. LAI&N: local anesthetic injectate and needle tip, PS: psoas major muscle, VB: vertebral body.

• 

  Fig. 4 Sonoanatomy for transversalis fascia plane block. EO: external oblique muscle, IO: internal oblique muscle, TA: transversus abdominis muscle, QL: quadratus lumborum muscle, PS: psoas major muscle.

• 

  Fig. 5 Picture showing spread of local anesthetic solution and needle tip for transversalis fascia plane block. Arrow pointing to target for local anesthetic solution deposition. TA: transversus abdominis muscle, QL: quadratus lumborum muscle, LAI&N: local anesthetic injectate and needle tip.

• 

  Fig. 6 Postoperative numerical pain rating score at rest. Data presented as mean ± standard deviation. QL: quadratus lumborum block, TF: transversalis fascia plane block.

• 

  Fig. 7 Postoperative numerical pain rating score with leg movement. Data presented as mean ± standard deviation. QL: quadratus lumborum block, TF: transversalis fascia plane block.

• 

  Fig. 8 Percentage of patients receiving postoperative rescue analgesia. QL: quadratus lumborum block, TF: transversalis fascia plane block.

• 

  Fig. 9 Duration of general anesthesia (GA), surgery, and block performance time. The error bars indicate the standard deviation. QL: quadratus lumborum block, TF: transversalis fascia plane block. *Means statistically significant difference.

Reference

1. Aasvang E, Kehlet H. 2005; Surgical management of chronic pain after inguinal hernia repair. Br J Surg. 92:795–801. DOI: 10.1002/bjs.5103. PMID: 15962258.

2. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al. 2016; Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 17:131–57. DOI: 10.1016/j.jpain.2015.12.008. PMID: 26827847.

3. Bulka CM, Shotwell MS, Gupta RK, Sandberg WS, Ehrenfeld JM. 2014; Regional anesthesia, time to hospital discharge, and in-hospital mortality: a propensity score matched analysis. Reg Anesth Pain Med. 39:381–6. DOI: 10.1097/AAP.0000000000000121. PMID: 25025697.

4. Hebbard PD. 2009; Transversalis fascia plane block, a novel ultrasound-guided abdominal wall nerve block. Can J Anaesth. 56:618–20. DOI: 10.1007/s12630-009-9110-1. PMID: 19495909.

5. Chakraborty A, Goswami J, Patro V. 2015; Ultrasound-guided continuous quadratus lumborum block for postoperative analgesia in a pediatric patient. A A Case Rep. 4:34–6. DOI: 10.1213/XAA.0000000000000090. PMID: 25642956.

6. Hansen CK, Dam M, Bendtsen TF, Børglum J. 2016; Ultrasound-guided quadratus lumborum blocks: definition of the clinical relevant endpoint of injection and the safest approach. A A Case Rep. 6:39. DOI: 10.1213/XAA.0000000000000270. PMID: 26771297.

7. Kumar GD, Gnanasekar N, Kurhekar P, Prasad TK. 2018; A comparative study of transversus abdominis plane block versus quadratus lumborum block for postoperative analgesia following lower abdominal surgeries: a prospective double-blinded study. Anesth Essays Res. 12:919–23. DOI: 10.4103/aer.AER_158_18. PMID: 30662131. PMCID: PMC6319076.

8. Webster K. 2008; The Transversus Abdominis Plane (TAP) block: abdominal plane regional anaesthesia. Update Anaesth. 24:24–9.

9. Carney J, McDonnell JG, Ochana A, Bhinder R, Laffey JG. 2008; The transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy. Anesth Analg. 107:2056–60. DOI: 10.1213/ane.0b013e3181871313. PMID: 19020158.

10. El-Dawlatly AA, Turkistani A, Kettner SC, Machata AM, Delvi MB, Thallaj A, et al. 2009; Ultrasound-guided transversus abdominis plane block: description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br J Anaesth. 102:763–7. DOI: 10.1093/bja/aep067. PMID: 19376789.

11. Carney J, Finnerty O, Rauf J, Curley G, McDonnell JG, Laffey JG. 2010; Ipsilateral transversus abdominis plane block provides effective analgesia after appendectomy in children: a randomized controlled trial. Anesth Analg. 111:998–1003. DOI: 10.1213/ANE.0b013e3181ee7bba. PMID: 20802056.

12. Aveline C, Le Hetet H, Le Roux A, Vautier P, Cognet F, Vinet E, et al. 2011; Comparison between ultrasound-guided transversus abdominis plane and conventional ilioinguinal/iliohypogastric nerve blocks for day-case open inguinal hernia repair. Br J Anaesth. 106:380–6. DOI: 10.1093/bja/aeq363. PMID: 21177284.

13. López-González JM, López-Álvarez S, Jiménez Gómez BM, Areán González I, Illodo Miramontes G, Padín Barreiro L. 2016; Ultrasound-guided transversalis fascia plane block versus anterior transversus abdominis plane block in outpatient inguinal hernia repair. Rev Esp Anestesiol Reanim. 63:498–504. DOI: 10.1016/j.redar.2016.02.005. PMID: 27067036.

14. Scimia P, Basso Ricci E, Petrucci E, Behr AU, Marinangeli F, Fusco P. 2018; Ultrasound-guided transversalis fascia plane block: an alternative approach for anesthesia in inguinal herniorrhaphy: a case report. A A Pract. 10:209–11. DOI: 10.1213/XAA.0000000000000666. PMID: 29652687.

15. Rahimzadeh P, Faiz SHR, Imani F, Rahimian Jahromi M. 2018; Comparison between ultrasound guided transversalis fascia plane and transversus abdominis plane block on postoperative pain in patients undergoing elective cesarean section: a randomized clinical trial. Iran Red Crescent Med J. 20:e67844. DOI: 10.5812/ircmj.67844.

16. Ahmed A, Fawzy M, Nasr MAR, Hussam AM, Fouad E, Aboeldahb H, et al. 2019; Ultrasound-guided quadratus lumborum block for postoperative pain control in patients undergoing unilateral inguinal hernia repair, a comparative study between two approaches. BMC Anesthesiol. 19:184. DOI: 10.1186/s12871-019-0862-z. PMID: 31623572. PMCID: PMC6798412.

17. Öksüz G, Bilal B, Gürkan Y, Urfalioğlu A, Arslan M, Gişi G, et al. 2017; Quadratus lumborum block versus transversus abdominis plane block in children undergoing low abdominal surgery: a randomized controlled trial. Reg Anesth Pain Med. 42:674–9. DOI: 10.1097/AAP.0000000000000645. PMID: 28759502.

18. Akerman M, Pejčić N, Veličković I. 2018; A review of the quadratus lumborum block and ERAS. Front Med (Lausanne). 5:44. DOI: 10.3389/fmed.2018.00044. PMID: 29536008. PMCID: PMC5834926.

19. Carline L, McLeod GA, Lamb C. 2016; A cadaver study comparing spread of dye and nerve involvement after three different quadratus lumborum blocks. Br J Anaesth. 117:387–94. DOI: 10.1093/bja/aew224. PMID: 27543534.

20. Yang HM, Park SJ, Yoon KB, Park K, Kim SH. 2018; Cadaveric evaluation of different approaches for quadratus lumborum blocks. Pain Res Manag. 2018:2368930. DOI: 10.1155/2018/2368930. PMID: 29991972. PMCID: PMC6016158.