It is planned to compare the postoperative analgesic efficacy of the Transversalis Fascia
Plane Block and the anterior Quadratus Lumborum Block in elective open inguinal hernia
surgeries.
Primary Objective: Our primary aim is to compare and evaluate the time to first rescue
analgesic requirement after the application of anterior Quadratus Lumborum Block and
Transversalis Fascia Plane Block in patients undergoing elective open inguinal hernia
surgeries under spinal anesthesia.
Secondary Objectives:
To compare the total analgesic consumption in the first 24 hours postoperatively.
To compare the Numeric Rating Scale (NRS) values (at rest and dynamic) of patients at
postoperative follow-ups at 2, 4, 8, 12, and 24 hours.
To compare postoperative side effects such as nausea and vomiting. In trunk blocks, local
anesthetic is applied to the interfascial area between the anterior abdominal wall or
back muscles. Due to the lack of blood circulation and vascularization in the
interfascial area, the absorption of local anesthetics is slow, allowing for prolonged
analgesic effects. For this reason, trunk blocks are used as part of multimodal
analgesia. The effectiveness of trunk blocks can vary based on the patient's structural
anatomical differences and previous surgeries, but an average analgesic effect of 8-12
hours is typically observed. Sometimes, analgesic effects have been reported to last up
to 24 hours.
Pain that arises from elective laparoscopic inguinal hernia surgeries can negatively
impact postoperative immobilization, atelectasis, pneumonia due to atelectasis, and
prolonged hospital stays. Due to the side effects associated with opioid medications used
for postoperative analgesia, such as nausea, vomiting, itching, constipation, and
dependency, non-opioid analgesic medications and regional techniques are used as part of
multimodal analgesia to reduce opioid use.
Quadratus Lumborum and Transversalis Fascia Blocks can be safely and easily performed,
especially in lower abdominal surgery, due to advancements in trunk blocks and ultrasound
technology in recent years.
This study aims to evaluate the postoperative analgesic efficacy of Quadratus Lumborum
Blocks and Transversalis Fascia Blocks administered to patients undergoing elective
inguinal hernia surgery. The Transversalis Fascia Block can be utilized in lower
abdominal surgeries by blocking the ilioinguinal, iliohypogastric nerves, and the T12
intercostal nerve. The Quadratus Lumborum Block provides analgesic efficacy in the T7-L2
dermatomal area.In patients planned for elective laparoscopic inguinal hernia surgery,
informed consent was obtained after detailed information was provided. The patients were
randomly divided into two groups using closed envelope randomization: the anterior
Quadratus Lumborum Block group and the Transversalis Fascia Block group.
All patients will be taken to the block room after the surgery. All blocks will be
performed under ultrasound guidance by the same anesthesia specialist while the patients
are in the lateral decubitus position, with the surgical sites facing up.
In the Quadratus Lumborum block group, in the lateral decubitus position, a convex
ultrasound probe will be sterilely placed in the subcostal area and above the iliac
crest. The quadratus lumborum and psoas major muscles, as well as the L4 vertebra's
transverse process, will be visualized. Using the in-plane technique and a 22G 100 mm
peripheral block needle, the placement will first be identified through hydrodissection
in the subfascial area between the quadratus lumborum and psoas major muscles. After
localization, 20 mL of 0.5% bupivacaine will be injected slowly, aspirating every 5 cc,
while visualizing the local anesthetic pushing the fascia in the ultrasound image.
In the Transversalis Fascia Block group, the same procedure will be followed as in the
Quadratus Lumborum block group, with the ultrasound probe being placed in the same
location, and the same in-plane technique will be applied with a 22G 100 mm peripheral
block needle. After hydrodissection, 20 mL of 0.5% bupivacaine will be injected slowly in
the same manner.
All patients will be monitored for 30 minutes in the block room after the block
application.
All patients will receive anesthesia using the same technique under spinal anesthesia
with bupivacain 12 mg intratechal space before surgery. At the end of the operation, all
patients will receive intravenous 1g of paracetamol for postoperative analgesia. Routine
extubation will be performed, and patients will be sent to the ward after recovery.
Postoperative analgesia for patients was planned as paracetamol 4x1g. Patients will be
followed up by a different blinded anesthesia assistant from the one who performed the
block at 2, 4, 8, 12, and 24 hours. The first rescue analgesia times, NRS scores
(evaluated on a scale of 1 to 10, where 0 means no pain and 10 means very severe pain),
postoperative side effects, and total analgesic amounts used in 24 hours will be
recorded.
In postoperative follow-ups, for patients with NRS scores greater than 3, intravenous
ibuprofen will be planned as rescue analgesia in the ward. If pain does not resolve
within 30 minutes, dexketoprophen 50 mg IV will be planned.
In trunk blocks, blocking the thoracoabdominal nerves that travel between the fascia with
local anesthetics is thought to provide analgesia during the postoperative period,
increasing patient comfort, reducing postoperative opioid consumption and dependency,
facilitating early mobilization, shortening the hospital stay, and minimizing opioid side
effects.
