Ultrasound-guided transversus abdominis plane block in combination with ilioinguinal-iliohypogastric block in a high risk cardiac patient for inguinal hernia repair: a case report

Background and Purpose: A high risk cardiac patient, ASA IV, was planned for inguinal hernia repair. Since general anaesthesia presented a high risk, anaesthesia was conducted with a transversus abdominis plane (TAP) in combination with ilioinguinal-iliohypogastric (ILIH) block. Material and Methods: A 70-year old male patient with severe CAD and previous LAD PTCA, AVR, in situ PPM and severe MR and TR 3+, was planned for elective inguinal hernia repair. The preoperative ECHO showed IVS dyskinesis with apicoseptal hypokinesis, global EF 42% and grade III diastolic dysfunction. The patient also suffered from hypertension, diabetes mellitus and had severe stenosis of both femoral arteries. Preoperative preparation included IBP monitoring while the TAP block was carried out under ultrasound guidance using an 8 Hertz linear probe. The ilioinguinal and iliohypogastric nerves were identified with ultrasound and peripheral nerve stimulator. Local anaesthetic [0.5% levobupivacaine (Chirocaine®, Abbott Laboratories) ] was applied in two locations: in the upper right fascia of the transversus abdominis muscle (15 ml) and around the right ilioinguinal and iliohypogastric nerves (10 ml), totalling a volume of 25 ml. Skin infiltration was performed with 5 ml 2% lidocaine [Lidocaine ®, Belupo] and 5 ml of normal saline. Results: Sensory block onset was at 28 minutes after administration and lasted for approximately 18 hours. There were no haemodynamic disturbances and the perioperative course was uneventful. Conclusion: During the first 18 postoperative hours, the patient was comfortable and satisfied with the anaesthetic procedure