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LETTER TO EDITOR
Year : 2017  |  Volume : 33  |  Issue : 1  |  Page : 132-133

Response to the letter for the article: Use of transversus abdominis plane block as an anesthetic technique in a high-risk patient for abdominal wall surgery


1 Department of Anaesthesia, Aga Khan University Hospital, Karachi, Pakistan
2 Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan

Date of Web Publication15-Mar-2017

Correspondence Address:
Samina Ismail
Department of Anaesthesia, Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi 74800
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.173327

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How to cite this article:
Ismail S, Khan MR, Urooj S. Response to the letter for the article: Use of transversus abdominis plane block as an anesthetic technique in a high-risk patient for abdominal wall surgery. J Anaesthesiol Clin Pharmacol 2017;33:132-3

How to cite this URL:
Ismail S, Khan MR, Urooj S. Response to the letter for the article: Use of transversus abdominis plane block as an anesthetic technique in a high-risk patient for abdominal wall surgery. J Anaesthesiol Clin Pharmacol [serial online] 2017 [cited 2017 Mar 28];33:132-3. Available from: http://www.joacp.org/text.asp?2017/33/1/132/173327

Sir,

With great interest, we read the article “transversus abdominis plane (TAP) block for surgical anesthesia-not ideal” by Rao Kadam. The authors have used TAP block in inguinal hernia and epigastric hernia repair in an elective setting. The authors have reported no pain on the surgical incision but encountered patient's discomfort on hernia sac manipulation. The reason for their surgical anesthesia “not ideal” is most probably related to the incorrect selection of a surgical procedure for TAP block anesthesia.

Our experience and the reported literature suggest the use of TAP block for anterior abdominal wall surgeries.[1],[2] The anatomy of the nerves involved in TAP block involves the anterior rami of the T6 to L1 spinal nerves traveling in the TAP before supplying the skin, muscles, and parietal peritoneum of the anterolateral abdominal wall. These nerve branches communicate widely within the TAP, creating a nerve plexus that is when injected with a local anesthetic, produces a multilevel neural blockade of the anterior hemi thorax from approximately T9 to L1.[3],[4],[5] However, the visceral innervation of the peritoneal cavity remains unaffected by TAP block. This could be the most probable explanation of pain encountered at the hernia sac manipulation and not at the skin incision, as reported by the authors of the above mentioned study.

In contrast to the case reported by Rao Kadam, we used TAP block in a semi emergency situation on the cardiovascular compromised patient.[1] The advantage of using TAP block in a hemodynamically compromised patient is the avoidance of both general and central neuraxial anesthesia, as both techniques cause varying degrees of myocardial depression and vasodilatation, which have a detrimental effect on the sympathetically driven circulation of these compromised patients. As anatomically, sympathetic and somatic innervations are closely related near the neuraxis, and become separated peripherally, therefore, nerve block like TAP block only affects somatic innervation and leave the sympathetic efferent intact.[3]

Ultrasound guided TAP block technique may be an attractive alternative to general anesthesia and central neuraxial technique for abdominal wall surgeries like wounds and abscesses not extending beyond the parietal peritoneum. However, the prospective investigation of this technique is required.

 
  References Top

1.
Ismail S, Khan MR, Urooj S. Use of transversus abdominis plane block as an anesthetic technique in a high risk patient for abdominal wall surgery. J Anaesthesiol Clin Pharmacol 2013;29:581-2.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Herring AA, Stone MB, Nagdev AD. Ultrasound-guided abdominal wall nerve blocks in the ED. Am J Emerg Med 2012;30:759-64.  Back to cited text no. 2
    
3.
Hebbard P, Fujiwara Y, Shibata Y, Royse C. Ultrasound-guided transversus abdominis plane (TAP) block. Anaesth Intensive Care 2007;35:616-7.  Back to cited text no. 3
    
4.
Tran TM, Ivanusic JJ, Hebbard P, Barrington MJ. Determination of spread of injectate after ultrasound-guided transversus abdominis plane block: A cadaveric study. Br J Anaesth 2009;102:123-7.  Back to cited text no. 4
    
5.
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. 5
    




 

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