Thoracic Erector Spinae Plane (T-ESP) Block Together With Intertransverse Process (ITP) Block for Laparoscopic Abdominal Surgery: A Case Report

Abstract

Laparoscopy has become a milestone with reduced surgical stress and postoperative pain. Evidence promotes erector spinae block for laparoscopic abdominal surgery, in particular for cholecystectomy. The thoracic paravertebral space block is the administration of local anesthetic into a wedge-shaped space on the antero-lateral thoracic spine and provides abdominal analgesia. We hypothesized that a combination of two paravertebral by proxy blocks (erector spinae and intertransverse process (ITP)) with multi-dermatomeric coverage and visceral pain control, with evidence for intra- and postoperative analgesia in thoracic and abdominal surgeries, may be a surgical anesthesia option for laparoscopy. A 42-year-old patient with gastroesophageal reflux disease (GERD) was scheduled for a laparoscopic Nissen fundoplication. He was 173 cm in height and weighed 90 kg (BMI 30 kg.m -2 ) and was classified in the American Society of Anesthesiologists Physical Status Classification System (ASA-PS) as 2. He had a history of difficult airway and refused general anesthesia. With the patient's informed written consent, we performed a bilateral thoracic erector spinae plane (T-ESP)/ITP blocks at the T4-8 level. Surgery was performed with the patient spontaneously breathing under sedation without complications. Hence, the combination of ESP-ITP blocks was a good anesthesia option for the planned surgery without side effects and optimal postoperative pain control.

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“…), without sacrificing the volume of the injectate and without excessively lowering the LA concentration under the minimum local anesthetic concentration (MLAC), i.e., under the minimum effective anesthetic/analgesic concentration. There is convincing evidence that the combination of perineural dexamethasone and dexmedetomidine can increase the potency and duration of the LA administered, as demonstrated by Pullano et al and other authors [7].…”

“…Hence, the anesthesiologist who performs these blocks must always be aware of the risk of LAST and wisely adjust LA concentrations, sometimes with the use of adjuvants (i.e., clonidine, dexmedetomidine, and dexamethasone). Besides dexamethasone, which has a well-established role as an adjuvant, dexmedetomidine has recently shown interesting properties, especially in combination with intrafascial or IV dexamethasone, increasing the potency of the mixtures, as well as the duration of sensory block [7,15]. Anyways, the volume of the injectate should not be reduced and the LA concentration should not be lowered under the minimum local anesthetic concentration (MLAC) for efficient analgesia.…”