hematoma after transversus abdominis plane block in a patient with hellp syndrome: a case report

Do transversus abdominis plane blocks reduce pain after laparoscopic colorectal surgery?

These authors reported that (lateral) transversus abdominis plane blocks decrease early and late dynamic pain on movement after laparoscopic colorectal surgery compared with placebo or no treatment, despite similar pain at rest and breakthrough opioid consumption.

What is an abdominal hematoma?

An abdominal hematoma can be intrabdominal or an abdominal wall hematoma. Abdominal wall hematoma usually results from bleeding inside the muscle layers of the abdominal wall, most commonly the vascular rectus muscle. A known category of this hematoma is rectus sheath hematoma.

Do plane blocks reduce postoperative pain after open hysterectomy?

Similarly to Zhou et al., 170 Bacal et al. 171 concluded that, compared with placebo or no block, posterior or lateral transversus abdominis plane blocks result in decreased early (2 h) and late (24 h) postoperative pain scores as well as a 10-mg lower morphine consumption at 24 h in patients undergoing open hysterectomy.

What is the history of transversus abdominis plane block?

The first description of transversus abdominis plane block is generally credited to Rafi, who, in 2001, advocated the performance of abdominal field block at the level of the lumbar triangle of Petit.

What is a hematoma in the abdominal wall?

A hematoma is a blood collection in an extravascular space and is named according to the location of the blood collection. Rectus sheath hematomas result from bleeding inside the vascular rectus muscle layer of the abdominal wall. This activity reviews the evaluation and management of rectus sheath hematomas and emphasizes the role of the interprofessional care team in recognizing and managing this condition.

What causes a hematoma in the posterior rectus sheath?

Rectus sheath hematoma is caused by rupture of an epigastric artery or one of its perforating branches. The vessel injury may be due to blunt or penetrating trauma, surgery, or strong contractions of the rectus muscle. Since the epigastric arteries run deep along the posterior rectus sheath, making a diagnosis during a physical exam is difficult, especially in patients who have obesity. The hematoma is usually posterior to the rectus muscle fibers, subcutaneous fat, and skin. Palpating a tender firm bulge is the most common physic exam finding. The fluctuation sign of a fluid collection is not usually possible to detect due to the deep location of the hematoma.  The lower quadrants of the abdomen are usually involved because of the long epigastric branches and the lack of a tamponade effect from the loose connective tissues of the rectus sheath.

What happens if you don't drain your rectus hematoma?

The main consequence of undiagnosed or untreated rectus hematomas is pain. In addition to pain, severe bleeding is serious and can be life-threatening. Therefore severe bleeding should be promptly identified and aggressively treated. Another potential complication is abscess formation. As in any blood collection that is not drained, there is always a chance of superseding infection and the development of an abscess. Draining of abscess becomes mandatory when it develops.

What is a hematoma in the rectus sheath?

Rectus sheath hematoma is bleeding in the rectus sheath. It is a confined space where the blood collects, commonly in the form of localized hematoma. Inferior or superior epigastric arteries and veins or their branches and tributaries form the basis of the bleeding source. A rectus hematoma can occur spontaneously in certain categories of people. But, it usually follows an injury to the inferior or superior epigastric vessels or their perforating branches. While this condition does resolve on its own, sometimes the hematoma can be extensive and lead to hypovolemic shock [4][5][6].

What is a hematoma?

A hematoma is a blood collection in an extravascular space. It results from bleeding from a vascular structure. Depending on the location of the blood collection, hematomas are named accordingly, e.g., intracranial hematoma[1], hemothorax[2], pelvic hematoma[3], and abdominal hematoma. Hematomas can collect in extravascular areas near bleeding vessels with space to accommodate this blood collection. An abdominal hematoma can be intrabdominal or an abdominal wall hematoma. Abdominal wall hematoma usually results from bleeding inside the muscle layers of the abdominal wall, most commonly the vascular rectus muscle. A known category of this hematoma is rectus sheath hematoma. This activity will be focused on rectus sheath hematoma or rectus hematoma.

How common is a rectus sheath hematoma?

Rectus sheath hematomas are uncommon [9][10].  The exact incidence of rectus sheath hematoma is not known as the condition is often misdiagnosed or undiagnosed. Some studies report an incidence of 1.5% to 2% in hospitalized patients.

What is the best treatment for hematoma?

If the hematoma is enlarging and or causing significant blood loss, intervention should be taken to stop the bleeding. Interventional radiology localizing and embolizing the bleeding vessel is the appropriate first modality of treatment to use. In most cases, this is successful and sufficient to stop the bleeding, especially with the confined space and the pressure created that counteracts the flow of bleeding.

What is the second most studied surgery for transversus abdominis plane blocks?

Laparoscopic cholecystectomy constitutes the second most studied surgery for transversus abdominis plane blocks. 15, 29–31, 50, 88, 137–144 The most recent meta-analysis investigating the efficacy of transversus abdominis plane blocks for laparoscopic cholecystectomy dates back to 2016. 145

What is a transversus abdominis plane block?

Since Rafi’s 1 2001 description, transversus abdominis plane blocks have become one of the most commonly performed truncal blocks. 2 They can be used to provide postoperative analgesia for open and laparoscopic abdominal surgery as well as inpatient and outpatient surgical procedures. 3 Transversus abdominis plane blocks remain a deceptively complex topic. For instance, not only can the transversus abdominis plane compartment be targeted using various approaches and techniques, but its size also requires a judicious dose of local anesthetic to ensure adequate postoperative pain control. More importantly, most approaches for transversus abdominis plane block only provide somatic ( i.e., abdominal wall) and not visceral analgesia. Thus, they may confer minimal benefits when compared with standard multimodal or thoracic epidural analgesia.

What adjuvants prolong the duration of transversus abdominis plane blocks?

In the literature, several adjuvants ( i.e., dexamethasone, alpha-2 agonists, magnesium, opioids, liposomal formulation) have been investigated to prolong the duration of transversus abdominis plane blocks.

What plane compartments can a surgeon target?

For instance, like anesthesiologists, surgeons can target all three (subcostal, lateral, and posterior) transversus abdominis plane compartments 48, 50 in the setting of open (laparotomy) 48 or laparoscopic 51 incisions.

Where can a truncal block be performed?

From an anatomical standpoint, abdominal truncal blocks can performed anywhere from neuraxial ( i.e., caudal block) and paraneuraxial ( e.g., thoracic paravertebral block, erector spinae plane block, retrolaminar, transmuscular quadratus lumborum blocks) locations to terminal compartments ( e.g., rectus sheath block) or terminal neural targets ( i.e., ilioinguinal and iliohypgastric nerve). To date, transversus abdominis plane blocks have been compared with a plethora of alternatives such as caudal blocks, 231–233 thoracic paravertebral blocks, 234 quadratus lumborum blocks, 235–238 rectus sheath blocks, 63, 64, 159, 239 and ilioinguinal and iliohypogastric nerve blocks. 233, 240–244 To highlight the best evidence, only randomized controlled trials published in PubMed-indexed journals were retained for analysis.

Where do transversus abdominis nerves leave?

Both leave the transversus abdominis plane compartment anterior to the middle third of the iliac crest and lie ventral to the internal oblique muscle and medial to the anterosuperior iliac spine. These nerves supply the anterior abdomen at the level of the inguinal area and the medial thigh. 5, 9.

Where do the lateral cutaneous branches of the T6–T11 spinal nerves depart from?

The lateral cutaneous branches of the T6–T11 spinal nerves depart from their respective anterior rami near the angle of the rib, or around the midaxillary line. 3, 5, 6 Thus, the lateral cutaneous branches arise before the main nerves penetrate the lateral transversus abdominis plane compartment ( fig. 1 ).