The analgesic efficacy of pre‐operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair

Abstract

Laparoscopic ventral hernia repair is an operation associated with significant postoperative pain, and regional anaesthetic techniques are of potential benefit. The erector spinae plane (ESP) block performed at the level of the T5 transverse process has recently been described for thoracic surgery, and we hypothesised that performing the ESP block at a lower vertebral level would provide effective abdominal analgesia. We performed pre-operative bilateral ESP blocks with 20-30 ml ropivacaine 0.5% at the level of the T7 transverse process in four patients undergoing laparoscopic ventral hernia repair. Median (range) 24-h opioid consumption was 18.7 mg (0.0-43.0 mg) oral morphine. The highest and lowest median (range) pain scores in the first 24 h were 3.5 (3.0-5.0) and 2.5 (0.0-3.0) on an 11-point numerical rating scale. We also performed the block in a fresh cadaver and assessed the extent of injectate spread using computerised tomography. There was radiographic evidence of spread extending cranially to the upper thoracic levels and caudally as far as the L2-L3 transverse processes. We conclude that the ESP block is a promising regional anaesthetic technique for laparoscopic ventral hernia repair and other abdominal surgery when performed at the level of the T7 transverse process. Its advantages are the ability to block both supra-umbilical and infra-umbilical dermatomes with a single-level injection and its relative simplicity.

Erector Spinae Plane Block Versus Retrolaminar Block

“…This was seen across 2 to 5 vertebral levels centered around the level of injection and provides a basis for the somatic and visceral analgesia that has been reported. [1][2][3][6][7][8][9][10][11][12][13] It also confirms the existence of anatomical pathways for anterior spread of local anesthetic. While the exact pathways have yet to be defined, they probably include the perforations in the intertransverse connective tissues through which the dorsal rami of spinal nerves and accompanying vessels emerge.…”

“…1,2 It involves injection of local anesthetic into the musculofascial plane deep to the erector spinae muscles and superficial to the tips of the transverse processes. Cadaveric and clinical evidence suggests that the local anesthetic may penetrate anteriorly through the intertransverse connective tissues into the paravertebral space where it acts on the ventral rami of spinal nerves 1,2 ; local anesthetic may also reach and block the rami communicantes and sympathetic chain to produce visceral analgesia.…”

The Erector Spinae Plane Block Provides Visceral Abdominal Analgesia in Bariatric Surgery

“…cases, together with a recently published report of its application in laparoscopic ventral hernia repair, 14 indicate that performing the ESP block at a lower vertebral level such as T7 can also provide effective and extensive abdominal analgesia. This is explained by the fact that the erector spinae muscle is a paraspinous column of muscle that extends from its origins from the sacrum and lumbar spinous processes to its insertions in the thoracic and cervical spine.…”

Interfascial Plane Blocks

“…4 Recently, a low thoracic injection in the ESP has been described for abdominal surgery. 12 In the lumbar area, the tissue plane deep to the ESP block is the same tissue plane superficial to the medial posterior aspect of the QL muscle (Fig. 3A).…”