The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair.
TL;DR: The ESP block is a promising regional anaesthetic technique for laparoscopic ventral hernia repair and other abdominal surgery when performed at the level of the T7 transverse process because of its ability to block both supra‐umbilical and infra‐umbillical dermatomes with a single‐level injection and its relative simplicity.
Abstract: Summary
Laparoscopic ventral hernia repair is an operation associated with significant postoperative pain, and regional anaesthetic techniques are of potential benefit. The erector spinae plane (ESP) block performed at the level of the T5 transverse process has recently been described for thoracic surgery, and we hypothesised that performing the ESP block at a lower vertebral level would provide effective abdominal analgesia. We performed pre-operative bilateral ESP blocks with 20–30 ml ropivacaine 0.5% at the level of the T7 transverse process in four patients undergoing laparoscopic ventral hernia repair. Median (range) 24-h opioid consumption was 18.7 mg (0.0–43.0 mg) oral morphine. The highest and lowest median (range) pain scores in the first 24 h were 3.5 (3.0–5.0) and 2.5 (0.0–3.0) on an 11-point numerical rating scale. We also performed the block in a fresh cadaver and assessed the extent of injectate spread using computerised tomography. There was radiographic evidence of spread extending cranially to the upper thoracic levels and caudally as far as the L2–L3 transverse processes. We conclude that the ESP block is a promising regional anaesthetic technique for laparoscopic ventral hernia repair and other abdominal surgery when performed at the level of the T7 transverse process. Its advantages are the ability to block both supra-umbilical and infra-umbilical dermatomes with a single-level injection and its relative simplicity.
Citations
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TL;DR: This cadaveric dye injection and dissection study was to simulate an erector spinae block to determine if dye would spread anteriorly to the involve origins of the ventral and dorsal branches of the thoracic spinal nerves.
334 citations
TL;DR: A series of 3 cases that illustrate the efficacy of bilateral ESP blocks performed at the level of the T7 transverse process for relieving visceral abdominal pain following bariatric surgery are described.
297 citations
Cites background from "The analgesic efficacy of pre-opera..."
...It is encased along its length in a fascial retinaculum (the thoracolumbar fascia),(15) which provides a conduit for craniocaudal spread of local anesthetic to multiple thoracic and even lumbar vertebral levels.(14) This is consistent with the sensory block from T7 to T11 observed in our third patient, as well as the clinical relief of his lower abdominal pain....
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TL;DR: The clinical effect of ESP and retrolaminar blocks can be explained by epidural and neural foraminal spread of local anesthetic, and the ESP block produces additional intercostal spread, which may contribute to more extensive analgesia.
270 citations
Cites methods from "The analgesic efficacy of pre-opera..."
...The erector spinae plane (ESP) block is an ultrasound-guided regional anesthetic technique for analgesia of the thoracic and abdominalwall.(1,2) It involves injection of local anesthetic into the musculofascial plane deep to the erector spinae muscles and superficial to the tips of the transverse processes....
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TL;DR: The ESPB appears to be a safe and effective option for multiple types thoracic, abdominal, and extremity surgeries and to the authors' knowledge, this is the first review providing a pooled review of ESPB characteristics.
248 citations
TL;DR: The study findings show that US-guided ESP block exhibits a significant analgesic effect in patients undergoing breast cancer surgery, and further studies are needed to identify the optimal analgesia technique for this group of patients.
206 citations
References
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TL;DR: The ESP block holds promise as a simple and safe technique for thoracic analgesia in both chronic neuropathic pain as well as acute postsurgical or posttraumatic pain.
1,283 citations
"The analgesic efficacy of pre-opera..." refers background or methods in this paper
...The ESP block is a novel ultrasound-guided technique that has recently been described for the management of acute and chronic thoracic pain [8]....
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...The ultrasound-guided erector spinae plane (ESP) block at the T5 transverse process is a recently-described technique for providing thoracic analgesia [8]....
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...However, the use of adjuncts such as dexamethasone may help prolong analgesia [28–30], and the ESP also lends itself well to catheter insertion for intermittent boluses [8] or continuous infusions of local anaesthetic....
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...Radiological imaging in a cadaver model further showed that a single injection at the level of the T5 transverse process produced cranio-caudal spread between C7 and T8, accounting for the extensive sensory block that was observed [8]....
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TL;DR: The three‐dimensional structure of the TLF and its caudally positioned composite will be analyzed in light of recent studies concerning the cellular organization of fascia, as well as its innervation.
Abstract: In this overview, new and existent material on the organization and composition of the thoracolumbar fascia (TLF) will be evaluated in respect to its anatomy, innervation biomechanics and clinical relevance. The integration of the passive connective tissues of the TLF and active muscular structures surrounding this structure are discussed, and the relevance of their mutual interactions in relation to low back and pelvic pain reviewed. The TLF is a girdling structure consisting of several aponeurotic and fascial layers that separates the paraspinal muscles from the muscles of the posterior abdominal wall. The superficial lamina of the posterior layer of the TLF (PLF) is dominated by the aponeuroses of the latissimus dorsi and the serratus posterior inferior. The deeper lamina of the PLF forms an encapsulating retinacular sheath around the paraspinal muscles. The middle layer of the TLF (MLF) appears to derive from an intermuscular septum that developmentally separates the epaxial from the hypaxial musculature. This septum forms during the fifth and sixth weeks of gestation. The paraspinal retinacular sheath (PRS) is in a key position to act as a ‘hydraulic amplifier’, assisting the paraspinal muscles in supporting the lumbosacral spine. This sheath forms a lumbar interfascial triangle (LIFT) with the MLF and PLF. Along the lateral border of the PRS, a raphe forms where the sheath meets the aponeurosis of the transversus abdominis. This lateral raphe is a thickened complex of dense connective tissue marked by the presence of the LIFT, and represents the junction of the hypaxial myofascial compartment (the abdominal muscles) with the paraspinal sheath of the epaxial muscles. The lateral raphe is in a position to distribute tension from the surrounding hypaxial and extremity muscles into the layers of the TLF. At the base of the lumbar spine all of the layers of the TLF fuse together into a thick composite that attaches firmly to the posterior superior iliac spine and the sacrotuberous ligament. This thoracolumbar composite (TLC) is in a position to assist in maintaining the integrity of the lower lumbar spine and the sacroiliac joint. The three-dimensional structure of the TLF and its caudally positioned composite will be analyzed in light of recent studies concerning the cellular organization of fascia, as well as its innervation. Finally, the concept of a TLC will be used to reassess biomechanical models of lumbopelvic stability, static posture and movement.
426 citations
"The analgesic efficacy of pre-opera..." refers background in this paper
...In the lower back this retinaculum is referred to as the thoracolumbar fascia [22]....
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TL;DR: Laparoscopic ventral and incisional hernia repair has been reported in a number of small trials to have equivalent or superior outcomes to open repair.
Abstract: Background:
Laparoscopic ventral and incisional hernia repair has been reported in a number of small trials to have equivalent or superior outcomes to open repair.
Methods:
Randomized controlled trials comparing laparoscopic and open incisional or ventral hernia repair with mesh that included data on effectiveness and safety were included in a meta-analysis.
Results:
Eight studies met the inclusion criteria. There was no difference between groups in hernia recurrence rates (relative risk 1·02 (95 per cent confidence interval (c.i.) 0·41 to 2·54)). Duration of surgery varied. Mean length of hospital stay was shorter after laparoscopic repair in six of the included studies; the longest mean stay was 5·7 days for laparoscopic and 10 days for open surgery. Laparoscopic hernia repair was associated with fewer wound infections (relative risk 0·22 (95 per cent c.i. 0·09 to 0·54)), and a trend toward fewer haemorrhagic complications and infections requiring mesh removal.
Conclusion:
Laparoscopic repair of ventral and incisional hernia is at least as effective, if not superior to, the open approach in a number of outcomes. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
317 citations
TL;DR: This anatomical study shows that an ultrasound-guided TAP injection cephalad to the iliac crest is likely to involve the T10-L1 nerve roots, and implies that the technique may be limited to use in lower abdominal surgery.
Abstract: Background The transversus abdominis plane (TAP) block is a new regional anaesthesia technique that provides analgesia after abdominal surgery. It involves injection of local anaesthetic into the plane between the transversus abdominis and the internal oblique muscles. The TAP block can be performed using a landmark technique through the lumbar triangle or with ultrasound guidance. The goal of this anatomical study with dye injection into the TAP and subsequent cadaver dissections was to establish the likely spread of local anaesthesia in vivo and the segmental nerve involvement resulting from ultrasound-guided TAP block. Methods An ultrasound-guided injection of aniline dye into the TAP was performed for each hemi-abdominal wall of 10 unembalmed human cadavers and this was followed by dissection to determine the extent of dye spread and nerve involvement in the dye injection. Results After excluding one pilot specimen and one with advanced tissue decomposition, 16 hemi-abdominal walls were successfully injected and dissected. The lower thoracic nerves (T10–T12) and first lumbar nerve (L1) were found emerging from posterior to anterior between the costal margin and the iliac crest. Segmental nerves T10, T11, T12, and L1 were involved in the dye in 50%, 100%, 100%, and 93% of cases, respectively. Conclusions This anatomical study shows that an ultrasound-guided TAP injection cephalad to the iliac crest is likely to involve the T10–L1 nerve roots, and implies that the technique may be limited to use in lower abdominal surgery.
304 citations
"The analgesic efficacy of pre-opera..." refers background in this paper
...Transversus abdominus plane blocks performed in the mid-axillary line only reliably cover the T10 to T12 dermatomes medial to the mid-clavicular line [23, 24] and thus may fail to anaesthetise the supra-umbilical and lateral portions of the mesh repair....
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TL;DR: The use of a bilateral paravertebral technique was found approximately to double the likelihood of inadvertent vascular punctures and to cause an eight-fold increase in pleural puncture and pneumothorax when compared with unilateral blocks.
Abstract: The failure rate and complications following thoracic and lumbar paravertebral blocks performed in 620 adults and 42 children were recorded. The technique failure rate in adults was 6.1%. No failures occurred in children. The complications recorded were: inadvertent vascular puncture (6.8%); hypotension (4.0%); haematoma (2.4%); pain at site of skin puncture (1.3%); signs of epidural or intrathecal spread (1.0%); pleural puncture (0.8%); pneumothorax (0.5%). No complications were noted in the children. The use of a bilateral paravertebral technique was found approximately to double the likelihood of inadvertent vascular puncture (9% vs. 5%) and to cause an eight-fold increase in pleural puncture and pneumothorax (3% vs. 0.4%), when compared with unilateral blocks. The incidence of other complications was similar between bilateral and unilateral blocks.
276 citations