Rev. Bras. Anestesiol. vol.64 número5

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REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

OfficialPublicationoftheBrazilianSocietyofAnesthesiology

www.sba.com.br

SCIENTIFIC

ARTICLE

Iliohypogastric/ilioinguinal

nerve

block

in

inguinal

hernia

repair

for

postoperative

pain

management:

comparison

of

the

anatomical

landmark

and

ultrasound

guided

techniques

Abdurrahman

Demirci,

Esra

Mercanoglu

Efe

∗

_,

_Gürkan

_Türker,

Alp

Gurbet,

Fatma

Nur

Kaya,

Ali

Anil, ˙Ilker

C

¸imen

DepartmentofAnesthesiologyandReanimation,UludagUniversityMedicalFaculty,Bursa,Turkey

Received4November2013;accepted2January2014 Availableonline6February2014

KEYWORDS

Inguinal herniorrhaphy; Iliohypogastric/ ilioinguinalnerve block;

Ultrasound; Landmark; Postoperativepain management; Levobupivacaine

Abstract

Objectives:Thepurposeofthisstudyistocomparetheefficacyofiliohypogastric/ilioinguinal nerveblocksperformedwiththeultrasoundguidedandtheanatomicallandmarktechniques forpostoperativepainmanagementincasesofadultinguinalherniorrhaphy.

Methods:40patients,ASAI---IIstatuswererandomizedintotwogroupsequally:inGroupAN (anatomicallandmarktechnique)andinGroupultrasound(ultrasoundguidedtechnique), ilio-hypogastric/ilioinguinalnerveblockwas performedwith20mlof0.5%levobupivacaineprior tosurgerywiththespecifiedtechniques.Painscoreinpostoperativeassessment,first mobi-lization time,duration ofhospitalstay, scoreofpostoperative analgesiasatisfaction,opioid inducedsideeffectsandcomplicationsrelatedtoblockwereassessedfor24hpostoperatively.

Results:VASscores at restinthe recovery room andall theclinical follow-up pointswere foundsignificantlylessinGroupultrasound(p<0.01orp<0.001).VASscoresatmovementin therecoveryroomandalltheclinicalfollow-uppointswerefoundsignificantlylessinGroup ultrasound (p<0.001 inalltime points).Whileduration ofhospital stayandthefirst mobi-lizationtimewerebeingfoundsignificantlyshorter,analgesiasatisfactionscoreswerefound significantlyhigherinultrasoundGroup(p<0.05,p<0.001,p<0.001respectively).

Conclusion:Accordingtoourstudy,USguidediliohypogastric/ilioinguinalnerveblockinadult inguinalherniorrhaphiesprovidesamoreeffective analgesiaandhighersatisfactionof anal-gesiathaniliohypogastric/ilioinguinal nerveblockwith theanatomicallandmark technique. Moreover,itmaybesuggestedthattheobservationofanatomicalstructureswiththeUSmay increasethesuccessoftheblock,andminimizetheblock-relatedcomplications.

∗_{Corresponding}_author.

E-mail:[email protected](E.M.Efe).

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PALAVRAS-CHAVE

Herniorrafiainguinal; Bloqueiodosnervos ílio-hipogástrico/ ilioinguinal; Ultrassom; Marco;

Manejodadorno pós-operatório; Levobupivacaína

Bloqueiodosnervosílio-hipogástrico/ilioinguinalemcorrec¸ãodehérniainguinalpara

tratamentodadornopós-operatório:comparac¸ãoentreatécnicademarcos

anatômicoseaguiadaporultrassom

Resumo

Objetivo: Compararaeficáciadebloqueiosdosnervosílio-hipogástrico/ilioinguinalfeitoscom atécnicaguiadaporultrassomeademarcosanatômicosparaomanejodadornopós-operatório emcasosdeherniorrafiainguinalemadultos.

Métodos: Foramrandomicamentedivididos40pacientes,estadofísicoASAI-II,emdoisgrupos iguais:nosgruposAN(técnicademarcosanatômicos)eUS(técnicaguiadaporultrassom),o bloqueiodosnervosílio-hipogástrico/ilioinguinalfoifeitocom20mLdelevobupivacaínaa0,5% antesdacirurgia comastécnicasespecificadas.Escore dedornaavaliaçãopós-operatória, tempo deprimeira mobilização,tempodeinternaçãohospitalar,escoredesatisfaçãocoma analgesia nopós-operatório, efeitos colateraisinduzidos por opiáceos ecomplicações rela-cionadasaobloqueioforamavaliadosdurante24horasdepós-operatório.

Resultados: EscoresEVAemrepousonasaladerecuperaçãoetodososvaloresclínicosduranteo acompanhamentoforamsignificativamentemenoresnogrupoultrassom(p<0,01oup<0,001). Escores EVA em movimento na sala de recuperação e todos os valores clínicos durante o acompanhamento foramsignificativamentemenoresno grupoultrassom(p<0,001 emtodos ostemposavaliados).Enquantoostemposdeinternaçãoedaprimeiramobilizaçãoforam sig-nificativamentemenores, osíndicesdesatisfaçãocomaanalgesiaforamsignificativamente maioresnogrupoultrasom(p<0,05,p<0,001,p<0,001,respectivamente).

Conclusão:Deacordocomonossoestudo,obloqueiodosnervosílio-hipogástrico/ilioinguinal guiadoporUSemherniorrafiasinguinaisemadultosproporcionaumaanalgesiamaiseficaze maiorsatisfaçãocomaanalgesiadoque comatécnicade marcosanatômicos. Alémdisso, pode-sesugerirqueaobservaçãodasestruturasanatômicascomaUSpodeaumentarosucesso dobloqueioeminimizarascomplicaçõesrelacionadasaobloqueio.

Introduction

Inguinalherniarepairisacommonsurgicalprocedure.1_The

incidenceis reportedas11/10,000 inpersonsbetween 16 and24 yearsof age, 200/10,000 inpersonsmore than 75 yearsofage.2_Chronic_pain_occurs_in_5---10%_after_the_inguinal

hernia repair that creates an important problem.3 _A

sig-nificant partof painafterhernia surgeryiscaused by the abdominalwall incision.4 _{Postoperative} _pain _management

in cases that undergo abdominal surgery is complicated. Despitethe effectivepainmanagementmethods, the fre-quencyofmoderateorseverepainisfoundtobe30---75%.5

Variousmethodsandmedicationsareusedin postopera-tive painmanagement.Peripheralnerve blockswithlocal anestheticsareamethodthatmaybeusedininguinalhernia surgeries for surgery and pain management. Iliohypogas-tric(IH) andilioinguinal(II) nerveblocksareusedfor this purpose.6---8

IH/IInerveblockmaybeperformedwiththeanatomical landmark(conventional,blindtechnique)orwithultrasound guidedtechniques.Therearestudieswheretheneedleentry pointisdefinedinthemedialspinailiacaanteriorsuperior inthe anatomicallandmarktechnique.7---13 _However,_there

arealsostudiespointingoutthatlumbarnerveoriginsand theprogressesofIH/IInervesintheanteriorabdominalwall mayvary.7---9,14_In_recent_years,_the_peripheral_regional_blocks

withtheultrasoundguidedhavebeenfoundouttobewith greatersuccess.

Thepurposeofthisstudy istocomparetheefficacyof IH/IInerveblocksperformedwiththeultrasoundguidedand theanatomicallandmarktechniquesforpostoperativepain managementincasesofadultinguinalherniorrhaphy.

Materials

and

methods

After approval Medical Researches Ethics Committee 40 cases between 18 and 80 years of ages, ASA (American SocietyofAnesthesiologist)I---IIclass,admittedtothe Gen-eralSurgery Clinicfor inguinal herniarepair wasincluded intothisprospective,randomizedandsingle-blindedstudy in Uludag University Medial Faculty, Health Practice and Research Center. Ethical approval for this study (Ethi-calCommitteeN◦ _{B.30.2.ULU.0.20.00.00.02.020/8189)}_was

providedbytheEthicalCommitteeofUludagUniversity Hos-pitals,Bursa,Turkey(ChairpersonProfS.Kılıcturgay)on23 June2009.

Allcaseswereinformedverballyaboutthepurposeand thecontentofthestudybeforethesurgeryandsigned writ-teninformedconsentformsweretakenfromtheoneswho agreedtoparticipatetothestudy.PatientswithASAIII---IV class,allergytolocalanesthetics,hemorrhagicdiathesisand clottingdisorderandwhorefusedthesurgerywereexcluded fromthestudy.

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• GroupAN(n=20):20mlof0.5%levobupivacaineforthe IH/IInerveblockwiththeanatomicallandmarktechnique

• GroupUS (n=20):20mlof0.5%levobupivacaineforthe IH/IInerveblockwiththeUSguidedtechnique.

Cases that were randomly selectedfor the IH/IInerve blockwiththeanatomicallandmarktechniquewere mon-itorized (ECG, pulse oximetry, noninvasive arterial blood pressure)in theprocedure room.Patientswere sedatized with 0.05mg/kg intravenous midasolam. Entry point was determinedin2cmmedialand2cmsuperior tothespina iliaca anteriorsuperior and skin wasdisinfected and cov-ered.Following thelocalanesthesia(LA)infiltration, 22G 8cmneedlewasadvancedthroughthecephalolateraland insertedtotouchthe innersurfaceof theileum.10mlof 0.5% levobupivacaine wasadministered into thelayers of theabdominalwallwhiletheneedlewaswithdrawn.Then, whiletheneedle wasadvancedwitharight angle, lossof resistancewasfeltduringthepassagethroughtheexternal oblique,internalobliqueandtransversusabdominismuscles respectivelyand10mlof0.5%levobupivacainewas admin-isteredintothemuscleswhiletheneedlewaswithdrawn.

Cases that were randomly selectedfor the IH/IInerve block with the US guided were monitorized (ECG, pulse oximetry,noninvasive arterial blood pressure)in the pro-cedure room. Patients were sedatized with 0.05mg/kg intravenous midasolam. The lateral abdominal wall was coveredwithasterilesanitarynapkinfollowingtheskin dis-infectionand8---12MHzlinearUSprobewasplaced inthe midaxillarylinebetweentheiliacwingandthecostal mar-ginin thetransverse plane.Theexternaloblique,internal obliqueandtransversus abdominismuscles were monitor-izedwiththeII andIHnerves.Following LAinfiltration,a 80mm 22 G stimulation needle (Stimuplex® _Ultra, _Braun,

Germany)was advanced aroundthe nerves with US guid-ance.While20mlof0.5%levobupivacainewasadministered atdivided doses,LAdispersionaroundboth of thenerves wassimultaneouslyobserved.

Thesensoryblocklevelwasassessedintherelatednerve innervation areawith the ‘‘pinpricktest’’ (analgesia test withneedle)following the II and IHnerveblock withthe anatomicallandmarksandUSguidedtechniques.

Following the IH/II blocks in the procedure room patients were taken into the operating room and moni-torizedwith theECG, noninvasivearterial blood pressure and pulse oximetry. 0.9% NaCl intravenous infusion was startedtoadminister.Aftergeneralanesthesiawasinduced with3mg/kg propofol IV, 2mcg/kg fentanyl IV, laryngeal mask airway was placed to the patients. Anesthesia was

maintained with sevoflurane and 40/60% mixture of oxygen/N2Owithadditionaldoseoffentanyl.

Attheend ofthesurgery patientswereawakened and taken to the postoperative recovery room. Postoperative painintensity wasassessedby ablind clinicanwithvisual analog scale (VAS, 0: no pain, 10: most severe pain to be estimated), at rest (VAS-R)and at movement (VAS-M), inpostoperative atthebeginningand 30thminutesin the recoveryroom;at2nd,4th,8th,12th,18thand24thhours inthesurgicalclinicandrecorded.Dexketoprofen50mgIV wasadministeredasarescueanalgesicwhenVAS-M≥4was recorded.Meperidin 1mg/kg IMwasplannedand adminis-teredwhenVAS-M≥4 wascontinued tobe recordedafter thefirstdoseofdexketoprofen.Inaddition,thefirst mobi-lizationtime,durationofhospitalstayandthepostoperative analgesiasatisfactionscore(0:poor,1:moderate,2:good, 3: verygood,4: excellent)wereevaluatedand recorded. Common side effects due to opioids in the postopera-tiveperiodsuchassedation,nausea-vomiting,constipation, allergic reactions; side effects due to the block in the operationareasuchasinfection,bowelperforation,pelvic hematoma, femoral nerve paralysis, and intraperitoneal injectionoflocalanestheticwereevaluatedandrecorded. Patients were questioned over the phone 1 week after discharge about pain, satisfaction of analgesia and block complications(infection,hematoma,nerveparalysis,etc.). Data were statistically analyzed with the SPSS 13.0 analysis software in the application laboratories of the UUFM Department of Biostatistics. In this study, con-tinuous and discrete variates are expressed in median (minimum---maximum) values, and categorical variables are expressed in frequency and percentage values. Mann Whitney U and chi-square test were used for intergroup comparisons. Percentage changes, values in the hemody-namicparameters,anddifferencescorebetweenVAS-Rand VAS-Mmeasurementswerecalculated.Whilerelatedvalues weretestedbetweengroupswiththeMannWhitney-Utest, intragroup comparisonswere realizedwith Wilcoxontest.

p<0.05wasconsideredtobestatisticallysignificant.

Results

None of 40 cases included to the study were excluded. No significant differencewasobserved between groups in terms ofdemographicdataandsurgerydurations ofcases (Table1).

Therewasnostatisticallysignificantdifferencebetween thegroupsinthesystolicarterialpressure,diastolicarterial pressureandheartratevaluesinalltheassessmentpoints

Table1 Demographicdataandsurgerydurationsofcases.

GroupUS GroupAN p-Value Age(year) 47(22---74) 58(25---76) 0.265 Bodymassindex(kg/m2₎ ₂₅_(20---32) ₂₄_(20---31) _0.925

ASAI/II(n) 16/4 11/9 0.183 Gender(M/F) 20/0 19/1 1.000 Surgeryduration(minute) 57(35---130) 60(30---90) 0.883

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duringtheintraoperativeandpostoperativeperiod. Periph-eral oxygen saturation was determined between 98% and 100%inbothgroupforallmeasurementpoints.

Thelengthofhospitalstay,thefirstmobilizationtimeand theanalgesiasatisfactionscoresofpatientsduring postop-erativeclinical follow-up arepresentedin Table 2.In the USgroupthedurationofhospitalstayandfirstmobilization timesweresignificantlyshorterandtheanalgesia satisfac-tionscoreswerefound tobesignificantlyhigher(p<0.05,

p<0.001,p<0.001respectively)(Table2).

When VAS at rest (VAS-R) was compared between the twogroups, VAS-Rscores of the groupUS in therecovery roomandalltheclinicalfollow-uppointswerefoundtobe lessstatisticallysignificantthanthegroupAN(p<0.01and

p<0.001)(Table3).

WhenVASatmovement(VAS-M)wascomparedbetween thetwogroups,VAS-MscoresofthegroupUSintherecovery roomandalltheclinicalfollow-uppointswerefoundtobe lessstatisticallysignificantthanthegroupAN(p<0.001in alltimes)(Table4).

Dexketoprofenwasusedin2cases(10%)intheUSgroup andin11cases(55%)intheANgroup;meperidinewasused in1caseintheUSgroup(5%)andin4casesintheANgroup (20%) asrescue analgesics in the recovery room.The use ofdexketoprofenasrescueanalgesicintheUSgroupswas foundtobelessstatisticallysignificant thantheANgroup (p=0.007).

There were noopioid-related treatment requiring side effectsor block relatedcomplications incases duringthe postoperativefollow-up.

Discussion

Followinginguinalherniasurgery,moderateorseverepain maycauseincreasethedurationofhospitalstay,unexpected rehospitalization,delayinreturningtonormalactivitiesand increaseinassociatedcosts.15,16_Callesen_et_al.16_found_out

moderateorseverepainscoresin60%ofcasesinthefirstday ofherniorrhaphyandin33%ofcasesinthe6thdayofsurgery. Moreover,it wassuggested thatinsufficient postoperative painmanagementfollowingherniorrhaphymight bea risk factorforthedevelopmentofchronicpain.17_Eklund_et_al.18

reportedmoderateorseverepain5yearsafterthe opera-tioninthe3.5%of705patientswhounderwentopenmesh repairofinguinalhernia.Inareviewwherethefrequencyof chronicpainaftermeshinguinalherniorrhaphywasstudied itwasreportedthat 11%ofpatients hadchronicpainand that approximately1/3 of these patients’ daily activities wereaffected.19

Multipleapproaches includingpharmacologywere used inthepainmanagementafterherniorrhaphybutanoptimal painmanagementhasnotbeenfoundyet.20

Table2 Hospitalstay,mobilizationtime,postoperativeanalgesiasatisfactionscoresinthepostoperativeperiod.

GroupUS GroupAN p-Value Hospitalstay 21(6---25) 24(14---26) 0.012 Mobilizationtime 75(30---180) 160(70---300) <0.001 Postoperativeanalgesiasatisfactionscore 5(3---5) 2(1---4) <0.001

Postoperativeanalgesiasatisfactionscores:0:poor,1:medium,2:good,3:verygood,4:excellent.Dataaremedian(min---max).

Table3 Visualanalogscalescoresofpainatrestinthepostoperativeperiod.

VAS-R(cm)

Recoveryroom Surgicalclinic

0min 30min 2h 4h 8h 12h 18h 24h GroupUS 0(0---5) 0(0---4) 1(0---3) 0(0---3) 0(0---4) 0(0---2) 0(0---1) 0(0---1) GroupAN 4(0---6) 3(0---4) 4(0---7) 3(0---6) 3(0---5) 3(0---4) 2(0---4) 2(0---3)

p-Value <0.001 <0.001 <0.001 <0.001 <0.001 0.008 0.004 0.008

VAS:0:nopain,10:mostseverepaintobeestimated.VAS-R:atrest.Dataaremedian(min---max).

Table4 Visualanalogscalevaluesofpainatmovementinthepostoperativeperiod.

VAS-M(cm)

Recoveryroom Surgicalclinic

0min 30min 2h 4h 8h 12h 18h 24h GroupUS 2(1---6) 2(0---6) 2(1---5) 2(1---4) 1(1---5) 1(0---2) 1(0---2) 1(0---2) GroupAN 5(0---8) 4(1---6) 4(2---6) 5(1---7) 4(0---7) 3(0---6) 3(0---5) 3(1---4)

p-Value <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.01

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Intheadultinguinalherniatreatmentguidelinethatwas publishedbyEuropean HerniaSociety in2009,ithasbeen suggested that considering local anesthesia for unilateral inguinal hernia, avoidingspinal anesthesia withhigh dose longactingagentsandthecombinationofgeneral anesthe-siawithlocalinfiltrationwithshortactingagentsmightbe an alternative to local anesthesia. Idealanesthetic tech-nique is identifiedasacceptable for the patient,suitable forsurgery,simpleandsafe,withlowriskofmorbidityand lowcost.21

Generalanesthesiamighthave somecomplicationslike airwaycomplications,cardiacinstability, nausea-vomiting, urinaryretentionandprolongedhospitalizationduetothe delayofrecoveryfromanesthesia.22_In_our_study,_we_did_not

observeanycomplicationrelatedtogeneralanesthesia. Local anesthesia,23---25_, _blockade _with _local _infiltration

technique,26,27_specific_blockade_of_IH/II_nerves_or_the

com-binationofthesetechniques28 _may_be_used_in_most_of_the

primary open inguinal herniorrhaphies in adults. In these proceduresithasbeen suggested thatintraoperative pain isthemostcommonreasonofpatient’sdissatisfaction.29,30

Thesetechniquesmaynotbeapplicableinyoung,anxious, morbidobesecasesandtheoneswithsuspected strangula-tion.Ithasbeentoldthatespeciallyinmorbidobesityand scrotalherniasthesuccess oflocalanesthesiadependson theclinican.28

Bhattacharya et al.31 _investigated _25,132 _cases

retro-spectivelywhounderwentunilateral and primary hernior-rhaphywithgeneral orlocoregionalanesthesiatechniques between 2005 and 2009. The duration of anesthesia and surgery,admission tothe postoperativerecovery unitand morbidity rates during 30 postoperative days were stud-ied. Cases with bilateral, femoral, recurrent, obstructed or gangrenous hernias and that would have a simulta-neoussecondsurgerywereexcluded.Whilehighcomorbidity rate and a little need of postoperative care were being found in the locoregional group, longerduration of anes-thesiaandsurgerywerefoundoutinthegeneralanesthesia group.Therewerenodifferencesin30daysmorbidityrates betweentwogroups.Followingtheequalizationof perioper-ativeriskfactorsithasbeensuggestedthatthelocoregional anesthesiawasasafeandefficientalternative.

O’ Dwyer et al.32 _evaluated ₂₇₆ _cases _who _underwent

inguinal herniorrhaphy under general anesthesiain terms of postoperative pain, recovery of psychomotor and cen-tralnervous system and cost. Amixture of lidocaineand bupivacaine wasadministered in divided doses under the skin, subcutan,subfascial and external oblique aponeuro-sis in the local anesthesiagroup. Wound infiltration with bupivacainewasperformed in both groups. No difference wasfoundbetweentwogroupsintermofhealingprofiles. Researcherssuggested thatthe choice of localor general anesthesiahadtobedecidedbyasurgeonandthepatient together.

Belletal.33_found_low_{postoperative}_morphine

consump-tionandreducedsideeffectsincasesofcesareanwithIH/II nerveblock.Gucev etal.34 _performed _effective_analgesia

in cases of cesarean with continuous IH/II nerve block throughcatheter.Postoperativemorphineconsumptionwas foundtobereduced51% inopenhysterectomycaseswith bilateralIH/IInerveblock.35_Wolfson_et_al.36_found_that_IH/II

nerveblockincesareancasesprovidedlowerpostoperative

recovery pain scores and dose of rescue analgesic. They also found out that preincisional bupivacaine with IH/II nerve block in adult patients whounderwent ambulatory open herniorrhaphy under spinal anesthesia reduced the predischarge pain score and dose of rescue analgesic.5

Also in our study in cases whom IH/II nerve block was performedwithUSguidance,dose ofrescueanalgesicand postoperativepainscoreswasfoundouttobelower.

IH/IInerveblockinpediatricgroupappearsinmany stud-ies.Markhametal.9_compared_IH/II_nerve_block_with_caudal

blockincasesofpediatricherniorrhaphyandorchiopexyand foundoutthatbothtechniqueshadsimilaranalgesiceffect. Lim etal.10 _found _out_that _the _blind _IH/II _nerve _block _in

pediatricinguinalherniorrhaphycasesprovidedhighparent satisfactionwiththereductionofpostoperativepain.

Anatomicallandmarkandultrasoundguidedtechniques forIH/IInerveblockareidentifiedintheliterature. Tradi-tionalanatomicallandmarktechniqueisnotcommonlyused becauseuseof highvolumesof localanestheticsand high failurerates.9,37

Weintraud et al.37 _studied _the _dispersion _of _the _local

anestheticinIH/IInerveblockperformedwiththe anatomi-callandmarktechniqueinpediatricinguinalherniorrhaphy. Blocks withuniform dispersion of localanesthetic around theIH/IInerveswithUSareconsideredaseffective(14%). Blocksthataredispersedintheadjacenttissuesare identi-fiedasineffective(86%)but24%oftheseblockswerealso clinicallyineffective.Clinicalsuccessrateoftheblockswas found61% inthisstudyconductedwith62cases.The suc-cessratewasfound72%inastudycomparingtheIH/IInerve blockperformedwithsingleanddoubleinjectiontechnique inchildren.10

Preventionofnervedamageandmanagementof effec-tive anesthesiainblind block procedureswithanatomical landmark is associated with the anatomical locations of the IH/II nerves and the contribution of lumbar nerves tothesenerves. Klaassen etal.38 _evaluated_the

contribu-tionrates of lumbar spinalnerves toIH/II nervesand the distances from the entry points of these two nerves into the abdominal wall to the spina iliaca anterior superior in 200 cadaver dissections. Lumbarspinal nerve contribu-tion rates to the II nerve were 65% L1, 14% T12---L1, 11%

L1---L2 and 10% L2---L3; to the IH nerve were 7% T12, 14%

T12---L1,10%L1,6%T11---T12.ItwasfoundthatIInerveenters

theabdominalwall2.8±1.1cmmedialand4±1.2cm infe-rior according to the spina iliaca anterior superior; IH nerve 2.8±1.3cm medial and 1.4±1.2cm inferior. Com-plexorigins of the IH/II nerves showedthat the sensorial componentsofthesenervesmayoriginatefromT11 andL3

spinallevels.Thisfindingiscompatiblewithmany anatom-ical studies in the literature. Nyhus39 _drew _attention _to

thecongruenceofconnectionsbetweentheII,IHand gen-itofemoral nerves withthesensorialsensoryfieldand the fact that this situation may be particularly important in regionalanesthesia.Weltetal.40 _performed_{paravertebral}

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Anatomicallandmarktechniquemaycausecomplications even in the experienced hands. Amory et al.41 _reported

intestinaldamagefollowingtheIH/IInerveblockwiththe anatomicallandmarktechniqueinpediatricherniorrhaphy. JöhrandSossai42_drew_attention_to_the_preferred_needle_size

inregionalblocksreportingcolondamageanddevelopment ofsubserosal hematoma.Anothercomplicationmentioned intheliteraturewastemporaryfemoralnerveparalysis.43---46

Ghanietal.47_determined_that_the_incidence_of_temporary

femoral nerve paralysis in adult herniorrhaphy cases was 6%.In ourstudy,therewasnoblock relatedcomplication inpatientswhohadIH/IInerveblockwiththeanatomical landmarktechnique.

Accordingtoourknowledge,therewasnopreviousstudy aboutefficacy,concentrationanddosesettingof levobupi-vacaineintheadultIH/IInerveblock.Howeverfewstudies areavailableinpediatricpatients.Dismaetal.48 _reported

that0.4ml/kgdoseoflevobupivacainewith0.25% concen-trationprovidedpostoperativeanalgesiainchildrenwhohad inguinal herniorrhaphy.It wasfoundthat theoptimal lev-obupivacainedosemight bereducedto0.075ml/kginthe IH/IInerveblockwiththeUSguidanceinchildren.49

Inourstudy,20mloflevobupivacainewith0.5% concen-tration wasused in both groups with efficacy and safety profile.Signsoflocalanesthetictoxicitywasnotobserved inanyofthecases.

Baerentzenetal.50_evaluated_the_efficacy_of_IH/II_nerve

blockwithUS in60,ASA I---II class,more than18yearsof agecaseswhounderwentunilateralinguinalherniorrhaphy. Afterinductionofgeneralanesthesia,caseshadUSguided IH/IInerveblockwithbupivacaineor saline.Primary mea-surement was defined as VAS pain score at movement in thepostoperativecareunit;secondarymeasurementswere definedasVASpainscoresatrest,opioidconsumption, post-operativenausea-vomiting,recoveryunitandlengthofstay intheclinic.Analgesicconsumption,painscore,perceived health statusand capabilitytodaily activities were ques-tioned over the phone at 24---48h after discharge. In the bupivacaine group; time of introduction to postoperative recovery unit, VAS scores at rest and movement at 30th minute,VASscores at restat dischargewerefound signif-icantlylower.VAS scoreat movementafter dischargewas found lowerin thebupivacainegroup butnot statistically significant (p=0.06). No significant difference was found in pain scores between two groups at the postoperative 24thand48thhours.Therewasnostatisticallysignificant differencebetween two groups in terms of postoperative opioid consumption in the recovery unit, clinic and after discharge(p=0.12,p=0.2,p=0.15).Perceivedhealth sta-tusandcapabilitytoperformdailyactivitieswereevaluated athomeoverthephoneandshowednodifferencebetween twogroups.In ourstudy,in caseswhereIH/IInerveblock wasperformedwithUSguidance,rescueanalgesicdosesand postoperativepain scores werefound lowerat the begin-ning and 30th minute in the postoperative recovery unit thatwascompatiblewiththeliterature.Painscoreat move-ment atdischarge wassignificantly lowerinthe US group thatwasdifferentfromtheliterature.Inourstudy,there was no significant difference in terms of pain, satisfac-tionofanalgesiaandcomplicationsoftheblockaccording to the evaluation made over the phone at home after discharge.

One limitation of our study was not to ask patients whethertheywouldpreferthesametechniqueornot.This wouldhavegivenmorereliableresultstous.

In conclusion, in adult inguinal herniorrhaphies, US guidedIH/IInerveblockprovidesamoreeffectiveand sat-isfied analgesia compared to IH/II nerve block with the anatomicallandmarktechnique.Ontheotherhand,itmay besuggestedthattheobservationofanatomicalstructures withtheUS might increase the success of the block,and minimizetheblock-relatedcomplications.

Conflicts

of

interests

Theauthorsdeclarenoconflictsofinterest.

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