Regional anesthesia for the practicing, general surgeon

Given the nation’s opioid crisis, health care workers are rapidly adapting to newer protocols to minimize postoperative opioid consumption while maintaining patient satisfaction with pain control and surgical recovery. The transversus abdominis plane (TAP) block is a regional anesthetic technique that has been effective for postoperative analgesia for several types of abdominal operations, while the ilioinguinal block has also shown efficacy in reducing postoperative pain following herniorrhaphy. In addition, the pectoral block has been shown to be efficacious when reducing pain following specific types of breast procedures.

These three techniques are classified as regional anesthetic peripheral nerve blocks and are traditionally performed using ultrasound by anesthesiologists. Recently, more surgical teams have been performing these procedures through laparoscopic and infiltrative approaches. This year’s skills didactic on regional anesthesia held Saturday, October 23, Regional Anesthesia Techniques: Abdominal Wall and Pectoral Blocks for the Practicing General Surgeon, showed surgeons how the implementation of these three blocks can benefit patient recovery and also contrasted an infiltrative and laparoscopic approach with traditional ultrasound-guided delivery of regional anesthesia.

The TAP block, when delivered laparoscopically, has been shown to reduce pain up to 24 hours in patients undergoing laparoscopic cholecystectomy, as published in Surgical Endoscopy earlier this year. In this study, surgeons delivered a four-quadrant TAP block with 10 ml of 0.25 percent bupivacaine at each of four sites. In a meta-analysis by Aamir et al published in Obesity Surgery, investigators performing laparoscopic bariatric operations found patients receiving a TAP block experienced less postoperative nausea and vomiting and decreased time to ambulation compared with patients who did not receive regional anesthesia, with opioid consumption and pain scores remaining the same between the two groups. Another small study (n=30 each group), the results of which were shared in Hernia, showed that those patients undergoing elective laparoscopic inguinal hernia repair with an L-TAP (30 ml of 0.25 percent bupivacaine) experienced less pain at three and six hours post-procedure compared with patients in the control group (15 ml of 0.5 percent bupivacaine at periportal sites). Groups receiving a TAP block or an ilioinguinal block following elective unilateral inguinal herniorrhaphy went significantly longer in the postoperative period before reporting pain (266 and 247 minutes, respectively) as compared with a control group (subarachnoid block only), as published in the Journal of Anesthesia.

As oncological breast surgery can be associated with significant acute and chronic postoperative pain, the Prospect guidelines endorse the use of pectoral nerve blocks as an alternative to paravertebral blocks. Furthermore, the guidelines also support the addition of local anesthetic wound infiltration to regional anesthesia techniques. A 2015 article in Regional Anesthesia & Pain Medicine by Bashandy et al found that patients who were undergoing elective unilateral modified radical mastectomy and who received either a pectoral I or II block in combination with general anesthesia fared better postoperatively than patients receiving general anesthesia alone (n=60 each group). Postoperative morphine consumption and visual analog scale pain scores were lower in the group receiving PECS blocks compared to the control group. A 2021 article in Anesthesiology reported that comparing the preoperative and postoperative advantages of a pectoral 1 block delivered via ultrasound to patients undergoing breast augmentation with a control group showed that preoperative PECS1 block resulted in reduced pain scores eight hours following surgery, lower opioid consumption, and less use of rescue analgesia.

The pectoral block session of the didactic course highlighted video-based education from Stephanie Valente, DO, FACS, director, Western Region Breast and Fairview Hospital Breast Programs, and director, Breast Surgical Oncology Fellowship, Cleveland Clinic, OH, and Scott Karlan, MD, FACS, director of information, department of surgery, and associate director, breast cancer, Cedars-Sinai Medical Center, West Hollywood, CA. A pre-recorded Panel Session followed. The TAP block technique video was followed by a live Panel Session moderated by Stefan Scholz, MD, FACS, assistant professor of surgery and director, minimally invasive surgery, University of Pittsburg, Children’s Hospital of Pittsburgh, PA, with speakers Jonah Stulberg, MD, PhD, MPH, FACS, vice-chair of research and associate professor of surgery, University of Texas Health Science Center, McGovern Medical School, Houston, and Shirin Towfigh, MD, FACS, hernia and laparoscopic surgery specialist, Beverly Hills Hernia Center, CA.

This didactic course will be followed in March (barring any further coronavirus 19-related delays) by an in-person skills course scheduled to take place on Wednesday, March 2, 2022, at the University of Chicago. For more information about the didactic course on October 23 or the skills course on March 2, contact Tarra Barot at [email protected] or access the resources for medical professionals webpage.