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LETTER TO EDITOR
Year : 2021  |  Volume : 41  |  Issue : 1  |  Page : 51-52

Surgically placed sub-costal transverse abdominis plane catheter as an alternative to ultrasound-guided technique in a converted cholecystectomy


Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission30-Mar-2020
Date of Decision08-May-2020
Date of Acceptance02-Jun-2020
Date of Web Publication25-Jul-2020

Correspondence Address:
Dr. Mridul Dhar
Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmedsci.jmedsci_70_20

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How to cite this article:
Dhar M, Kumar A, Selvaraj N. Surgically placed sub-costal transverse abdominis plane catheter as an alternative to ultrasound-guided technique in a converted cholecystectomy. J Med Sci 2021;41:51-2

How to cite this URL:
Dhar M, Kumar A, Selvaraj N. Surgically placed sub-costal transverse abdominis plane catheter as an alternative to ultrasound-guided technique in a converted cholecystectomy. J Med Sci [serial online] 2021 [cited 2021 Mar 1];41:51-2. Available from: https://www.jmedscindmc.com/text.asp?2021/41/1/51/290730



Dear Editor,

A 47-year-old, 70 kg female patient was scheduled to undergo laparoscopic cholecystectomy. Clinical examination and biochemical profile revealed no abnormality. The patient was obese with a body mass index of 33 kg/m[2]. On the day of the surgery, anesthesia was induced normally and the airway was secured with a proseal laryngeal mask airway. Laparoscopic ports were inserted, and pneumo-peritoneum was established. Due to adhesions and difficult anatomy, it was decided to convert to open procedure. Analgesia was supplemented with fentanyl. The abdomen was opened through a right sub-costal incision, and the rest of the procedure was uneventful.

As an ultrasonography (USG) machine was not immediately available, and placing an epidural catheter (EC) was not a feasible option at that time, the surgeon was requested to place an 18G EC in the sub-costal transverse abdominis plane (TAP) between the rectus abdominis and transverse abdominis muscles before closing the abdominal layers. The epidural needle was inserted approximately 5 cm from the caudal edge of the incision in the mid-clavicular line and the needle tip was brought out in the sub-costal TAP [Figure 1]a. The catheter was inserted from the skin into the TAP under vision and 8 cm length was kept in the plane [Figure 1]b. The catheter was fixed at the skin with sutures, and sterile dressing was applied at the end of the surgery [Figure 2]. 20 ml 0.25% bupivacaine was injected into the TAP catheter prior to extubation, along with systemic analgesics. The patient had a visual analog scale score of 2–3 in the recovery room. Repeat injection of 20–30 ml of 0.125% bupivacaine was given 8 hourly along with paracetamol. Rescue opioid in the form of intravenous tramadol was given once on the 1st postoperative day. The patient had an uneventful postoperative course, with pain scores being <4 throughout. The sub-costal TAP catheter was removed on the 3rd postoperative day.
Figure 1: (a) Insertion of epidural needle into the caudal edge of incision and brought out in the transverse abdominis plane. (b) Illustration of anterior abdominal muscle layers and correct position of the catheter (EN: Epidural needle, EC: Epidural catheter, U: Umbilicus, RA: Rectus abdominis, EO: External oblique, IO: Internal oblique, TA: Transversus abdominis)

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Figure 2: Epidural catheter inserted into the transverse abdominis plane

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USG-guided classical TAP block or posterior TAP between the internal oblique and transverse abdominis muscles has become a regular and reliable regional technique to provide peri-operative analgesia for lower abdominal surgeries (T-10 to L-1). The sub-costal TAP block although less commonly used can be given in surgeries extending above the umbilicus.[1],[2] There is ambiguity regarding the amount of cranial spread of the drug using the sub-costal approach. A reliable spread has been seen from T-9 to T-11 but has also been reported up to T-6, especially when using multiple injection technique under USG guidance.[1],[2],[3] Many reports of its use are generally seen in cases where laparoscopic procedures had to be converted to open or when EC was not placed initially.[1],[4]

Regional and fascial plane blocks are an important component of multimodal analgesia, taking care of the somatic component of postoperative pain, and should be given in all cases where feasible. USG-guided sub-costal TAP block using multiple injections from xyphoid to iliac crest has been found to be more efficacious than a single-shot technique.[1],[2] Placing a catheter also produces opioid-sparing effect, and can avoid the side effects of ECs.[2]

Placing the catheter surgically through the incision between the intended muscle layers under vision has been practiced by authors previously for elective open cases of nephrectomy, hepatectomy, etc.[2],[5] This can also be a useful technique in unanticipated laparoscopic surgeries getting converted to open, as in the present case. This technique has the advantage of the catheter being placed under vision, which can be of particular significance in obese patients where catheter placement may be difficult even with USG guidance. It also saves time and can help in faster turnover of a busy operation theater, compared to performing the block under USG at the end of the procedure, which may further delay recovery. In the current case, the drug was injected at the time of skin closure, and the patient could be reversed without any delay. The drug spread could be confirmed by USG later in the recovery room.

Although USG-guided block is the gold standard in terms of safety and efficacy for fascial blocks, surgically placed catheters can be a suitable alternative, especially in the absence of preprocedural ECs or unavailability of USG.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mukherjee A, Guhabiswas R, Kshirsagar S, Rupert E. Ultrasound guided oblique subcostal transversus abdominis plane block: An observational study on a new and promising analgesic technique. Indian J Anaesth 2016;60:284-6.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Niraj G, Kelkar A, Powell R. Ultrasound-guided subcostal transverses abdominis plane block. Int J Ultrasound Appl Technol Perioper Care 2010;1:9-12.  Back to cited text no. 2
    
3.
Barrington MJ, Ivanusic JJ, Rozen WM, Hebbard P. Spread of injectate after ultrasound-guided subcostal transversus abdominis plane block: A cadaveric study. Anesthesia. 2009;64:745-50.  Back to cited text no. 3
    
4.
Chen CK, Phui VE. The efficacy of ultrasound-guided oblique subcostal transversus abdominis plane block in patients undergoing open cholecystectomy. Southern Afr J Anesthesia Analgesia 2011;17:308-10.  Back to cited text no. 4
    
5.
Harish R, Forastiere E, Sofra M. Low-dose infusion with 'surgical transverse abdominis plane (TAP) block' in open nephrectomy. Br J Anesthesia 2009;102:889-90.  Back to cited text no. 5
    


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