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      Improved perioperative analgesia with ultrasound-guided ilioinguinal/iliohypogastric nerve or transversus abdominis plane block for open inguinal surgery: a systematic review and meta-analysis of randomized controlled trials

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          Abstract

          [Purpose] Ultrasound-guided ilioinguinal/iliohypogastric (II/IH) nerve and transversus abdominis plane (TAP) blocks have been increasingly utilized in patients for perioperative analgesia. We conducted this meta-analysis to evaluate the clinical efficacy of ultrasound-guided II/IH nerve or TAP blocks for perioperative analgesia in patients undergoing open inguinal surgery. [Subjects and Methods] A systematic search was conducted of 7 databases from the inception to March 5, 2015. Randomized controlled trials (RCTs) comparing the clinical efficacy of ultrasound-guided vs. landmark-based techniques to perform II/IH nerve and TAP blocks in patients with open inguinal surgery were included. We constructed random effects models to pool the standardized mean difference (SMD) for continuous outcomes and the odds ratio (OR) for dichotomized outcomes. [Results] Ultrasound-guided II/IH nerve or TAP blocks were associated with a reduced use of intraoperative additional analgesia and a significant reduction of pain scores during day-stay. The use of rescue drugs was also significantly lower in the ultrasound-guided group. [Conclusion] The use of ultrasound-guidance to perform an II/IH nerve or a TAP block was associated with improved perioperative analgesia in patients following open inguinal surgery compared to landmark-based methods.

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          Comparison between ultrasound-guided transversus abdominis plane and conventional ilioinguinal/iliohypogastric nerve blocks for day-case open inguinal hernia repair.

          F Cognet, Huy Le, P Vautier … (2011)
          Transversus abdominis plane (TAP) block has been reported to provide effective analgesia after lower abdominal surgery, but there are few data comparing ilioinguinal/iliohypogastric nerve (IHN) block with ultrasound-guided TAP block in patients undergoing inguinal hernia repair. Two hundred and seventy-three patients undergoing day-case open inguinal hernia repair with a mesh were randomly allocated to receive either ultrasound-guided TAP block or blind IHN block with levobupivacaine 0.5%, before surgery. Patients were monitored for visual analogue scale (VAS) scores at rest (in the post-anaesthesia care unit, and at 4 and 12 h) and at rest and during movement (at 24, 48 h, 3 and 6 months). Pain at 6 months was also assessed using the DN4 questionnaire for neuropathic pain. Median VAS pain scores at rest were lower in the ultrasound-guided TAP group at 4 h (11 vs 15, P=0.04), at 12 h (20 vs 30, P=0.0014), and at 24 h (29 vs 33, P=0.013). Pain after the first 24 h, at 3 and 6 months after surgery, and DN4 scores were similar in both groups (P=NS). The proportion of patients with VAS >40 mm on movement at 6 months was comparable {18.2% [95% CI (12.2-26.1%)] vs 22.4% (15.8-30.6%) in the TAP and IHN groups, respectively, P=0.8}. Postoperative morphine requirements were lower during the first 24 h in the TAP block group (P=0.03). Ultrasound-guided TAP block provided better pain control than 'blind' IHN block after inguinal hernia repair but did not prevent the occurrence of chronic pain.
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            Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children.

            S Kapral, Carol Johnston, A Bösenberg … (2005)
            The ilioinguinal/iliohypogastric nerve block is a popular regional anaesthetic technique for children undergoing inguinal surgery. The success rate is only 70-80% and complications may occur. A prospective randomized double-blinded study was designed to compare the use of ultrasonography with the conventional ilioinguinal/iliohypogastric nerve block technique. One hundred children (age range, 1 month-8 years) scheduled for inguinal hernia repair, orchidopexy or hydrocele repair were included in the study. Following induction of general anaesthesia, the children received an ilioinguinal/iliohypogastric block performed either under ultrasound guidance using levobupivacaine 0.25% until both nerves were surrounded by the local anaesthetic or by the conventional 'fascial click' method using levobupivacaine 0.25% (0.3 ml kg(-1)). Additional intra- and postoperative analgesic requirements were recorded. Ultrasonographic visualization of the ilioinguinal/iliohypogastric nerves was possible in all cases. The amount of local anaesthetic used in the ultrasound group was significantly lower than in the 'fascial click' group (0.19 (SD 0.05) ml kg(-1) vs 0.3 ml kg(-1), P<0.0001). During the intraoperative period 4% of the children in the ultrasound group received additional analgesics compared with 26% in the fascial click group (P=0.004). Only three children (6%) in the ultrasound-guided group needed postoperative rectal acetaminophen compared with 20 children (40%) in the fascial click group (P<0.0001). Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks can be achieved with significantly smaller volumes of local anaesthetics. The intra- and postoperative requirements for additional analgesia are significantly lower than with the conventional method.
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              Ilioinguinal/iliohypogastric blocks in children: where do we administer the local anesthetic without direct visualization?

              Stephan Kapral, Peter Marhofer, Harald Willschke … (2007)
              Ultrasonographic observation of peripheral nerve blocks enables direct visualization of the spread of local anesthetic around the targeted nerves. Similarly, ultrasonography may be used to determine the site of local anesthetic placement when landmark-based techniques are used. We performed a study to determine the actual location of local anesthetic when ilioinguinal/iliohypogastric nerve blocks are performed using landmark-based techniques in children in an attempt to explain a failed block. After induction of general anesthesia (1 minimum alveolar anesthetic concentration halothane and laryngeal mask airway), 62 children scheduled for inguinal surgery received an ilioinguinal/iliohypogastric nerve block based on standard anatomical landmarks. Ultrasonography was then used to determine the actual location of local anesthetic placement. The anesthesiologist performing the block was blinded to the ultrasonographic investigation. Successful blocks were recorded either when the local anesthetic surrounded the nerves or were based on clinical signs after skin incision. In 14% of the blocks, the local anesthetic was administered correctly around the nerves resulting in successful blocks. In the remaining 86%, the local anesthetic was administered in adjacent anatomical structures (iliac muscle 18%, transverse abdominal muscle 26%, internal oblique abdominal muscle 29%, external oblique abdominal muscle 9%, subcutaneous 2%, and peritoneum 2%), and 45% of these blocks failed. Accurate placement of local anesthetic around the ilioinguinal/iliohypogastric nerves in children is seldom possible when landmark-based techniques are used. In the majority of patients, the local anesthetic was inaccurately placed in adjacent anatomical structures with unpredictable block results.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Phys Ther Sci
                Journal ID (iso-abbrev): J Phys Ther Sci
                Journal ID (publisher-id): JPTS
                Title: Journal of Physical Therapy Science
                Publisher: The Society of Physical Therapy Science
                ISSN (Print): 0915-5287
                ISSN (Electronic): 2187-5626
                Publication date (Electronic): 31 March 2016
                Publication date (Print): March 2016
                Volume: 28
                Issue: 3
                Pages: 1055-1060
                Affiliations
                [1) ] Department of Anesthesiology Pain Division, Mayo Clinic, USA
                [2) ] Department of Ultrasound Medicine, Chinese PLA General Hospital, China
                [3) ] Department of Physical Medicine and Rehabilitation, Mayo Clinic, USA
                [4) ] Department of Physical Medicine and Rehabilitation, Sir Run Run Shaw Hospital, College of Medicine of Zhejiang University, China
                [5) ] Department of Library-Public Services, Mayo Clinic, USA
                [6) ] Center for the Science of Healthcare Delivery, Mayo Clinic, USA
                Author notes
                [* ]Corresponding author. Wenchun Qu, Department of Anesthesiology Pain Division, Mayo Clinic: 200 First Street SW, Rochester, MN, 55905, USA. (E-mail: qu.wenchun@ 123456mayo.edu )
                Article
                Publisher ID: jpts-2015-846
                DOI: 10.1589/jpts.28.1055
                PMC ID: 4842423
                PubMed ID: 27134411
                SO-VID: 548f5201-f808-41df-a4fe-b27034c8a0c6
                Copyright © 2016©by the Society of Physical Therapy Science. Published by IPEC Inc.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License.

                History
                Date received : 28 October 2015
                Date accepted : 15 December 2015
                Categories
                Subject: Review

                Keywords: ultrasound,ilioinguinal/iliohypogastric nerve,inguinal surgery
                Data availability:
                Keywords: ultrasound, ilioinguinal/iliohypogastric nerve, inguinal surgery

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