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Year : 2016  |  Volume : 10  |  Issue : 1  |  Page : 25-28

Ultrasound-guided rectus sheath and transversus abdominis plane blocks for perioperative analgesia in upper abdominal surgery: A randomized controlled study

1 Department of Anesthesia, Faculty of Medicine, Ain Shams University, Cairo, Egypt; King Fahd Specialist Hospital, Dammam, Saudi Arabia
2 Department of Anesthesia, Faculty of Medicine, King Fahd Specialist Hospital, Dammam, Saudi Arabia

Correspondence Address:
Khaled Abdelsalam
Amer Bin Thabet Street, P.O. Box 15215, Dammam 31444, Saudi Arabia

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-354X.169470

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Date of Web Publication13-Jan-2016


Background: Regional anesthetic techniques can be used to alleviate postoperative pain in patients undergoing major upper abdominal surgery. Our aim was to evaluate the efficacy of bilateral ultrasound (US)-guided rectus sheath (RS) and transversus abdominis plane (TAP) blocks for better perioperative analgesia.
Patients and Methods: It is a prospective, observer-blinded, randomized clinical study. 40 eligible patients undergoing elective liver resection or Whipple procedure were included. All patients received a standardized anesthetic technique. Group 1 (n = 20) received preincisional US-guided bilateral RS and TAP blocks using 20 ml volume of bupivacaine 0.25% for each, and group 2 (n = 20) received local wound infiltration at end of surgery with 40 ml of bupivacaine 0.25%. A standardized postoperative analgesic regimen composed of intravenous paracetamol and a morphine patient-controlled analgesia (PCA). The use of intraoperative fentanyl and recovery room morphine boluses, PCA-administered morphine, pain scores as well as number of patients' experienced postoperative nausea and vomiting in the ward at 6 and 24 h were recorded.
Results: Group 1 patients received a significantly lower cumulative intraoperative fentanyl, significantly lesser boluses of morphine in postanesthesia care unit, as well, significantly lower cumulative 24 h postoperative morphine dosage than the group 2 patients. Pain visual analog scale scores were significantly lower at both 6 and 24 h postoperatively in TAP group when compared with the no-TAP group. There were no complications related to the TAP block procedures. No signs or symptoms of local anesthetic systemic toxicity were detected.
Conclusion: The combination of bilateral US-guided RS and TAP blocks provides excellent perioperative analgesia for major upper abdominal surgery.

Keywords: Abdominal surgery; analgesia; rectus sheath; transversus abdominis plane block; ultrasound

How to cite this article:
Abdelsalam K, Mohamdin O W. Ultrasound-guided rectus sheath and transversus abdominis plane blocks for perioperative analgesia in upper abdominal surgery: A randomized controlled study. Saudi J Anaesth 2016;10:25-8

How to cite this URL:
Abdelsalam K, Mohamdin O W. Ultrasound-guided rectus sheath and transversus abdominis plane blocks for perioperative analgesia in upper abdominal surgery: A randomized controlled study. Saudi J Anaesth [serial online] 2016 [cited 2022 Jun 26];10:25-8. Available from:

  Introduction Top

A significant pain experienced by patients after major upper abdominal surgery like liver resection and Whipple's procedure is derived from the abdominal wall incision. [1] Epidural analgesia remains the gold standard for pain control for abdominal surgical procedures. [2] Nevertheless, complications from epidural analgesia include hypotension, bradycardia, dural puncture, spinal infection, and rarely, but terribly, neurological damage. [3] Moreover, removal of the epidural catheters possibly will provide challenges and additional danger if patients develop coagulopathy on the basis of liver dysfunction. [4] Due to these risks, many anesthesiologists do not routinely insert epidurals for patients undergoing major liver resections. The idea of transversus abdominis plane (TAP) block is to anesthetize part of - or the entire - abdominal wall instead of using intrathecal or epidural techniques. Since the first description of the TAP block technique, this block has been increasingly used to provide somatic anesthesia of the antero-lateral abdominal wall. [5],[6],[7],[8] Hebbard et al. described the US-guided continuous oblique subcostal TAP block. [9] Each can be done as a single shot or continuous catheter infusion technique, as well a combination of one or more can be done on a single side or both hemi-abdomens. The bilateral dual TAP (BD-TAP) block based on four single shot injections, aiming to anesthetize the entire abdominal wall. [7] The four injections of BD-TAP are; the epigastric area just below the xiphoid process medially to the costal curvature (subcostal) block, and the lateral classic TAP block in the lower abdomen on both hemi-abdomens. In our study, we replaced the subcostal TAP block by rectus sheath (RS) block. The central portion of the anterior abdominal wall is innervated by the ventral branches of the thoracolumbar nerves (Th6-L1). The ventral branches lie deep to the RA muscle but ventral to the posterior RS. The RS block has been utilized to provide analgesia for midline incisions and laparoscopic procedures. [6] RS block may also be effective in reducing postoperative pain in upper abdominal surgery as an alternative method of epidural analgesia in anticoagulated patients. [10] Therefore, in our study, we combined RS and TAP blocks for possible better perioperative analgesia in upper abdominal surgery.

  Patients and Methods Top

After Local Medical Ethics Review Board approval, 40 patients scheduled for major upper abdominal surgery were enrolled in this study. This is a prospective; observer-blinded, randomized clinical study, conducted at King Fahd Specialist Hospital. Eligible patients were recruited after getting written, informed consents. Patients were excluded if they had any contraindication for RS or TAP blocks, any known allergy for bupivacaine, physical or mental conditions which may vague measuring postoperative pain following surgery. Patients with morbid obesity (body mass index ≥40) were also excluded. Patients were randomized allocated into one of the two groups; block group (group 1) or local infiltration group (group 2). All patients received a standardized anesthetic technique for induction with 100-200 mcg fentanyl, 2-3 mg/kg propofol, and 0.15 mg/kg cisatracurium. Maintenance was achieved with oxygen/air sevoflurane, and intraoperative titration of intravenous (IV) fentanyl. Group 1 received preincisional ultrasound (US)-guided Bilateral RS and TAP blocks using 20-ml volume of bupivacaine 0.25% for each, and group 2 received local wound infiltration of 40 ml of bupivacaine 0.25% at end of surgery. Preincisional US-guided RS and TAP blocks were done by one of the authors with significant previous experience in US-guided techniques and after that not involved in the collection of the studied data. The surgeon and operating room staff (anesthesiologists and nurses) were not blinded to the treatment group. However, the patient and family, recovery room nurses, and study coordinator who collected the data were blinded. After aseptic preparation of the injection sites, a US transducer (linear 6-13 MHz, SonoSite M-Turbo ® , Brothell, WA) (covered with sterile sheath) was used. A 22-gauge 10 mm insulated needle (Stimuplex ® A, B-Braun Medical, Melsungen, Germany) is inserted in-plane to the transducer in a medial to lateral direction with the endpoint in the fascial plane between the rectus muscle and posterior RS or between the internal oblique and transversus abdominis muscles (TAP block). After negative aspiration, 20 ml of bupivacaine 0.25% was injected. The spread of the injectate should be observed to be distributed within these planes. The type of skin incisions included extended right subcostal incision which is appropriate for different operations on the liver, gallbladder and biliary tract and transverse incision for pancreatic surgery as Whipple's procedure, total pancreatectomy, and distal pancreatectomy. Antiemetic regimen consisted of 8 mg dexamethasone (IV) administered at induction and 4 mg ondansetron (IV) administered at the completion of surgery. All patients were managed in the postanesthesia care unit (PACU) where, 2 mg boluses of IV morphine were given if needed every 5 min if pain score was equal or more than 5, with maximum dose of 10 mg. In ward, postoperative analgesic regimen composed of six hourly IV paracetamol (1 g) and patient-controlled analgesia morphine delivering a bolus of 1 mg, 6-min lockout, and maximum 4 h dose limit of 25 mg. The use of intraoperative fentanyl, PACU morphine boluses, and number of patients' experienced postoperative nausea and vomiting (PONV), as well as pain scores at 6 and 24 h following completion of surgery were recorded. Patient-reported pain scores were assessed with a visual analog scale (VAS) ranging from 0 to 10 with 0 denoting no pain and 10 denoting the maximal pain imaginable.


Categorical data were expressed as numbers (%) and compared using a Chi-square or Fisher's exact test as appropriate. Continuous data with a parametric distribution were presented with means and standard deviations (SDs) and compared using an independent t-test, whereas nonparametric data were expressed as median and inter-quartile range and compared with a Mann-Whitney U-test. A result was deemed significant when P < 0.05.

Sample size calculation

Based on our unpublished data of mean differences and SD of intraoperative fentanyl and postoperative morphine usage, we hypothesized a 50% reduction in fentanyl and morphine usage because of bilateral RS and TAP block administration. We calculated that <20 patients were required in each group to give 80% power at a 5% significance level.

  Results Top

Forty patients were recruited into this study. There were no significant differences in demographic or operative data [Table 1]. Group 1 patients received a lower cumulative intraoperative fentanyl dose 360 (SD 88.3) μg than group 2 patients 580 (SD 91.8) microgram with a statistically significant P = 0.0001. In the PACU, group 1 patients needed smaller amounts of morphine (1 [SD 6.5] mg] than the group 2 patients, who needed 5.6 (SD 1.54) mg with statistically significant P < 0.0001. As well, group 1 patients needed a lower cumulative 24 h postoperative morphine dosage 11 (SD 4.59) mg than the group 2 patients, who used 38.6 (SD 9.17) mg with a statistically significant P < 0.0001 [Table 2]. Total number of patients reported PONV at 24 h following surgery was 8 (40%) in the TAP block group compared to 12 (60%) in the control group, but it was statistically nonsignificant [Table 2]. Pain VAS scores were significantly lower in group 1 than group 2 at both 6 h postoperatively (2.19 [1-4] vs. 4.8 [3-7]) and 24 h postoperatively (2.5 [2-6] vs. 4 [3-7]) [Table 3]. There were no complications related to the RS or TAP block procedures. No signs or symptoms of local anesthetic systemic toxicity were detected.
Table 1: Patients characteristics and duration of surgery

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Table 2: IO and PO opioid usage and incidence of PONV

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Table 3: VAS scores at different time points in patients receiving TAP catheters or epidural analgesia

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  Discussion Top

Optimal analgesia is an essential aspect of adequate recovery after major abdominal surgery. Regional analgesia of the abdominal wall can provide good analgesia for a variety of surgical operations especially when used as part of a multimodal technique. Between the internal oblique and transversus abdominis muscles lies a plane that contains the anterior rami of the lower six thoracic nerves (T7 to T12) and first lumbar nerve (L1), supplying the skin, muscles, and parietal peritoneum, this study was based on our experience with TAP block that proposed the technique was effective analgesic intervention for kidney transplant recipients. The clinical importance of our findings is the significant opioid-sparing effects of bilateral RS and TAP blocks both in the intraoperative as well as the postoperative period. Opioids, though very effective in perioperative pain management, may be associated with nausea-vomiting, pruritus, and respiratory depression. Moreover, some patients who are morbidly obese or having obstructive sleep apnea will be maximally benefitted from bilateral RS and TAP blocks through the opioid-sparing effects. Besides this, bilateral RS and TAP blocks also prevent the hemodynamic responses of surgical incision, so patients having ischemic heart disease or stenotic valvular lesion like mitral or aortic stenosis, where tachycardia is undesirable, will also be benefitted from preincisional bilateral RS and TAP blocks. These blocks may be a relatively safer alternative to neuraxial block for perioperative analgesia in patients having coagulopathy as it would occur in our cases of liver resections.

Our study has a few limitations. First, it is tricky to recognize insufficient analgesia intraoperatively. Though we controlled the depth of anesthesia by BIS monitoring, ensured adequate muscle relaxation, prevented hypovolemia, indirect assessment of intraoperative pain by hemodynamic parameters may be imperfect. Second, we evaluated the postoperative pain at only 2 time periods (6 and 24 h) and only at rest, which is NOT the optimal, we would recommend for further comparative studies to increase the frequency and measure the VAS both at rest and on coughing.

  Conclusion Top

The combination of bilateral US-guided RS and TAP blocks provide excellent perioperative analgesia for major upper abdominal surgery.

Financial support and sponsorship


Conflict of interest

There are no conflicts of interest.

  References Top

Rozen WM, Tran TM, Ashton MW, Barrington MJ, Ivanusic JJ, Taylor GI. Refining the course of the thoracolumbar nerves: A new understanding of the innervation of the anterior abdominal wall. Clin Anat 2008;21:325-33.  Back to cited text no. 1
Clarke H, Chandy T, Srinivas C, Ladak S, Okubo N, Mitsakakis N, et al. Epidural analgesia provides better pain management after live liver donation: A retrospective study. Liver Transpl 2011;17:315-23.  Back to cited text no. 2
Horlocker TT, McGregor DG, Matsushige DK, Schroeder DR, Besse JA. A retrospective review of 4767 consecutive spinal anesthetics: Central nervous system complications. Perioperative Outcomes Group. Anesth Analg 1997;84:578-84.  Back to cited text no. 3
Page A, Rostad B, Staley CA, Levy JH, Park J, Goodman M, et al. Epidural analgesia in hepatic resection. J Am Coll Surg 2008;206:1184-92.  Back to cited text no. 4
Rafi AN. Abdominal field block: A new approach via the lumbar triangle. Anesthesia 2001;56:1024-6.  Back to cited text no. 5
Abrahams MS, Horn JL, Noles LM, Aziz MF. Evidence-based medicine: Ultrasound guidance for truncal blocks. Reg Anesth Pain Med 2010;35 2 Suppl:S36-42.  Back to cited text no. 6
Børglum J, Jensen K, Christensen AF, Hoegberg LC, Johansen SS, Lönnqvist PA, et al. Distribution patterns, dermatomal anesthesia, and ropivacaine serum concentrations after bilateral dual transversus abdominis plane block. Reg Anesth Pain Med 2012;37:294-301.  Back to cited text no. 7
El-Dawlatly AA, Trkistani A, Kettner SC, Machata AM, Delvi MB, Thallaj A, et al. Ultrasound-guided transversus abdominis plane block: Description of a new technique and comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br J Anaesth 2009;109:763-7.  Back to cited text no. 8
Hebbard PD, Barrington MJ, Vasey C. Ultrasound-guided continuous oblique subcostal transversus abdominis plane blockade: Description of anatomy and clinical technique. Reg Anesth Pain Med 2010;35:436-41.  Back to cited text no. 9
Osaka Y, Kashiwagi M, Nagatsuka Y, Oosaku M, Hirose C. Ultrasound-guided rectus sheath block for upper abdominal surgery. Masui 2010;59:1039-41.  Back to cited text no. 10


  [Table 1], [Table 2], [Table 3]

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