P052: ULTRASOUND GUIDED TRANSVERSUS ABDOMINIS PLANE BLOCK BLOCK WITH BOTOX FOR COMPLEX HERNIA REPAIR
David Habibian, MD; Thomas Disanto, MD; William Grubb, MD, DDS
Robert Wood Johnson University Hospital, NJ Pain Instutute
Introduction/Background: Complex abdominal wall defects, such as ventral hernias, are defined by experts as loss of domain or hernia volumes greater than 30% of abdominal contents (1). They have been increasing in prevalence and can arise from a variety of factors, such as trauma, previous surgeries, and congenital defects (2). While they can have wide-ranging effects on patients’ lives, these defects can be challenging surgical cases. Botulinum toxin A (botox) works at presynaptic nerve terminals to prevent the release of acetylcholine into the neuromuscular junction, resulting in paralysis. Using botox during transverse abdominal plane (TAP) blocks has therefore been shown to facilitate abdominal wall closure (3). In this case, we describe TAP blocks performed with botox at the surgeon’s request to aid in hernia reduction for a 62-year-old male undergoing ventral hernia repair and transversus abdominis release (TAR).
Methods: The patient is a 62-year-old male, with a past medical history of schizophrenia and a large ventral hernia that failed prior surgical repair. He was found to have a hernia measuring greater than 10 cm with loss of domain and severe excess skin. He was scheduled for open repair with general surgery requiring bilateral component separation and transfascial fixation sutures, and the pain management team was consulted for pre-operative TAP blocks with botox to facilitate surgical reduction in the future. These blocks were done under sedation by perioperative regional block service two weeks prior to his surgery. The patient was placed in the supine position with appropriate monitors, and the injection site was prepared and draped under sterile conditions with chlorhexidine. The three layers of abdominal musculature were identified in the subcostal and iliohypogastric region, and a 21 g echogenic block needle was advanced under ultrasound guidance until it was just below the internal oblique muscle. After negative aspiration, 2 mL of oxabotulinumtoxin A (25 U/mL) were administered into the plane, and the procedure was repeated on the contralateral side, both without complications.
Results: On the day of his surgery, the patient received bilateral erector spinae regional nerve blocks. These blocks were done under ultrasound guidance, and the injectate included 10 mL of liposomal bupivacaine 1.3% and 10 mL of 0.25% bupivacaine on each side. The hernia repair was then performed under general anesthesia without complications, and the patient was discharged several days later. At his follow-up visit with surgery 2 weeks later, the patient reported eating normally, healed incisions, well-controlled pain, and improved physical activity.
Discussion/Conclusion: Ventral hernias and other complex abdominal wall defects can significantly impact patients’ physical functioning and mental well-being and can be challenging surgical cases. TAP blocks performed with botox, however, are a viable treatment option due to the ability to provide flaccid paralysis to abdominal musculature. As evidenced by the treatment of this patient, these injections should be considered in conjunction with surgical repair.
Image 1: Left-sided TAP Block US image
Image 2: Right-sided TAP Block US image