Dual Transversus Abdominis Plane Research Articles

A comparative evaluation of ultrasound guided dual transversus abdominis plane block versus erector spinae plane block for postoperative analgesia in patients undergoing laparoscopic cholecystectomy: A randomised prospective study

: Effective pain control after laparoscopic cholecystectomy (LC) is crucial for early patient mobilization, facilitating a speedy recovery and avoiding several complications. Ultrasound (USG) guided bilateral dual transversus abdominis plane block (DTAPB) and erector spinae plane block (ESPB) are effective for providing postoperative pain relief after LC.A prospective randomised, study comprising of 100 patients posted for elective LC. To compare the effectiveness of USG-guided DTAPB and ESPB for providing postoperative pain relief in patients undergoing LC. A total of 100 patients aged 18-70 years, were included in the study and divided into two groups of 50 patients each. Group DTAPB received bilateral DTAPB and group ESPB received bilateral ESPB, using 50 ml of 0.25% ropivacaine with 8 mgs of dexamethasone. Post operative visual analogue score (VAS) score, time to first analgesia request, total number of analgesic doses required in 24 hours (hrs) and complications if any were noted. VAS score was higher in DTAPB group than ESPB group at 1,2,6,8 and 14 hrs. In DTAPB group patients requested analgesia after an average of 8 ±2.0 hrs, whereas in ESPB group they requested after 12 ± 3.16 hrs. In ESPB group 45 patients needed single analgesic dose and only 5 needed second analgesic doses. However, in DTAPB group 35 patients received single and 15 patients received second analgesic dose. Side effects were comparable in both the groups.USG-guided bilateral ESPB with 50 ml of 0.25% ropivacaine plus dexamethasone is an effective approach in reducing postoperative pain following LC.

Retraction Note: Efficacy of dexmedetomidine as an adjunct to ropivacaine in bilateral dual-transversus abdominis plane blocks in patients with ovarian cancer who underwent cytoreductive surgery

This article has been retracted. Please see the Retraction Notice for more detail: https://doi.org/10.1186/s12871-022-01731-4.

RETRACTED ARTICLE: Efficacy of dexmedetomidine as an adjunct to ropivacaine in bilateral dual-transversus abdominis plane blocks in patients with ovarian cancer who underwent cytoreductive surgery

ObjectiveWe sought to evaluate the postoperative control of pain and recovery in patients with ovarian cancer who underwent cytoreductive surgery by adding dexmedetomidine to ropivacaine in bilateral dual-transversus abdominis plane (Bd-TAP) blocks.MethodsWe enrolled 90 patients with an American Society of Anesthesiologists physical status I to III undergoing open abdominal cytoreductive surgery in this study. Patients were randomized and assigned into three groups (TAP-R, TAP-DR, or CON) of 30 participants each. All of the patients received standardized general anesthesia, and postoperative Bd-TAP blocks were performed. The TAP-R, TAP-DR, and CON groups received Bd-TAP blocks with 0.3% ropivacaine, 0.3% ropivacaine and 0.5 μg/kg of dexmedetomidine, and 0.9% normal saline, respectively. All of the patients received patient-controlled analgesia (PCA) (formula, 100 μg of sufentanil and 16 mg of ondansetron diluted with normal saline to 100 mL). Flurbiprofen axetil was used as a rescue drug if the visual analog scale (VAS) score was more than four points. The first request time for PCA bolus; the VAS scores at 0, 6, 12, 24, and 48 h after operation; and the cumulative sufentanil consumption within 24 and 48 h, respectively, were compared. Pulmonary function was evaluated preoperatively and at 24 h after the operation. The use of the rescue drug was recorded. Postoperative functional recovery, including time to stand, time to walk, time to return of bowel function, time to readiness for discharge, and postoperative complications, were recorded.ResultsMedian values of the first request time for PCA of the TAP-R group was significantly prolonged compared to that of the CON group (median [interquartile range], 7.3 [6.5–8.0] hours vs. 3.0 [2.3–3.5] hours) (P < .001), while the TAP-DR group has the longest request time among the three groups (median [interquartile range], 13.5 [12.4–14.5] hours) (P < .001). The VAS scores at rest and upon coughing of the TAP-R group in the first 12 h were significantly lower than those of the CON group (P < 0.05), but showed no significant difference compared to those of the TAP-DR group. The VAS scores at rest and upon coughing were lower in the TAP-DR group at each time point compared to those of the CON group (P < .05). The cumulative sufentanil consumption in the TAP-DR group was significantly lower at 48 h (P = .04) after surgery than in the CON group, while there was no significant difference compared to that in the TAP-R group (P > .05). Less rescue analgesic was required by patients in the TAP-DR group than in the CON group (P < .05). Postoperative mean measured forced expiratory volume in 1 s (FEV1) and FEV1/forced vital capacity values in the TAP-DR group were significantly higher than those of the CON group (P = .009), while there was no significant difference compared to those of the TAP-R group (P = .10). There was no significantly difference in postoperative functional recovery between TAP-DR and CON group (P > 0.05).ConclusionTAP blocks can provide effective pain relief up to 12 h postoperatively without a significant improvement in postoperative pulmonary function. The addition of dexmedetomidine to ropivacaine for Bd-TAP block prolonged the first bolus time of PCA when compared to that in the TAP-R group and decreased sufentanil consumption and the need of rescue analgesia relative to in the CON group at 48 h postoperative. The procedure provided better postoperative analgesia and improved postoperative pulmonary function relative to the CON group. Our results indicate that dexmedetomidine as an adjuvant of Bd-TAP can provide effective pain relief up to 48 h.

Impact of Bilateral Subcostal Plus Lateral Transversus Abdominis Plane Block on Quality of Recovery After Laparoscopic Cholecystectomy: A Randomized Placebo-Controlled Trial.

Previous research has not evaluated the potential effect of transversus abdominis plane (TAP) block on quality of recovery following laparoscopic cholecystectomy. Therefore, we investigated whether addition of the bilateral subcostal and lateral TAP (bilateral dual TAP [BD-TAP]) blocks to multimodal analgesia would improve the quality of recovery as assessed with the Quality of Recovery-40 (QoR-40). Patients age 18 to 60 years who were scheduled to undergo elective laparoscopic cholecystectomy were randomized to the BD-TAP or control group. The BD-TAP group received the BD-TAP block with multimodal analgesia under general anesthesia, using 0.25% ropivacaine, and the control group was treated with the same method, except that they received the sham block using 0.9% normal saline. Both groups had the same multimodal analgesia regimen, consisting of intravenous dexamethasone, propacetamol, ibuprofen, and oxycodone. The primary outcome was the QoR-40 score at 24 hours after surgery. Data were analyzed using the independent t test, Mann-Whitney U test, χ2 test, and Fisher exact test. Thirty-eight patients in each group were recruited. The mean QoR-40 score decreased by 13.6 (95% confidence interval [CI], 8.3-18.8) in the BD-TAP group and 15.6 (95% CI, 6.7-24.5) in the control group. The postoperative QoR-40 score at 24 hours after surgery did not differ between the 2 groups (BD-TAP group, median [interquartile range], 170.5 [152-178]; control group, 161 [148-175]; median difference, 3 [95% CI, -5 to 13]; P = .427). There were no differences between the 2 groups in the pain dimension of the QoR-40: 30.5 (95% CI, 27-33) in the BD-TAP group and 31 (95% CI, 26-32) in the control group; median difference was 0 (95% CI, -2 to 2); P = .77. Our results indicate that the BD-TAP block does not improve the quality of recovery or analgesic outcomes following laparoscopic cholecystectomy. Our results do not support the routine use of the BD-TAP block for this surgery.

The Safety and Efficacy of Ultrasound-Guided Bilateral Dual Transversus Abdominis Plane (BD-TAP) Block in ERAS Program of Laparoscopic Hepatectomy: A Prospective, Randomized, Controlled, Blinded, Clinical Study.

PurposePostoperative pain management for patients undergoing hepatic resection is still a challenge due to the risk of perioperative liver dysfunction. The transversus abdominis plane (TAP) block is a promising regional analgesic technique. However, the correct guidelines regarding the dose and regimen of local anesthetics in patients undergoing hepatic resection have yet to be established completely. This study aimed to evaluate the safety and efficacy of ultrasound-guided BD-TAP block with a large dose of ropivacaine in laparoscopic hepatectomy.Patients and MethodsThis prospective, blinded, randomized, controlled study was conducted with 50 patients who were scheduled for selective laparoscopic hepatectomy. Patients who received a BD-TAP block (3 mg/kg of ropivacaine diluted to 60 mL) with general anesthesia were categorized into the BD-TAP block group (n = 25), and those who received general anesthesia were categorized into the control group (n = 25). The primary outcomes were consumption of sufentanil within 48 hours post-operation and plasma ropivacaine concentration. The secondary outcomes were the severity of pain (at rest and upon coughing), nausea and/or vomiting, and quality of recovery.ResultsCompared with the control group, the patients in BD-TAP block group had a significant reduction of postoperative sufentanil consumption at 2 hours (P = 0.019), 24 hours (P = 0.001), and 48 hours (P = 0.001), and the visual analog scale (VAS) scores on coughing were significantly lower at postoperative 2 hours (P = 0.004). There were no statistically significant differences in postoperative nausea and/or vomiting, flatus, catheter removal, off-bed activity, liver function, or postoperative hospital stay. The mean peak total ropivacaine concentration was 1,067.85 ng/mL, which occurred 1 hour after administering the block, and mean free ropivacaine concentration was 52.32 ng/mL. The highest individual peak plasma concentration was 2,360.90 ng/mL at 45 min postinjection, and the free ropivacaine concentration was 139.29 ng/mL.ConclusionUltrasound-guided BD-TAP block provides effective postoperative analgesia after laparoscopic hepatectomy. This study also confirms that ultrasound-guided BD-TAP blocks with 3 mg/kg ropivacaine during laparoscopic hepatectomy almost never results in the plasma ropivacaine concentrations associated with neurotoxicity.

Comparing post-operative analgesic effects of varying doses of dexmedetomidine as an adjuvant to ropivacaine for ultrasound-guided dual transversus abdominis plane block following laparotomy for gynecologic malignancies.

The aim of the present study was to determine the analgesic effects of ropivacaine combined with different doses of dexmedetomidine for ultrasound-guided transversus abdominis plane (TAP) block immediately following laparotomy in patients with gynecologic malignancies. A further aim was to determine the appropriate clinical dose of dexmedetomidine as an adjuvant for ropivacaine. Patients with gynecologic malignancies scheduled for laparotomy were randomly assigned to group R (TAP block with 0.3% ropivacaine), group RD1 (TAP block with ropivacaine and 0.5 µg/kg dexmedetomidine), group RD2 (TAP block with ropivacaine and 1 µg/kg dexmedetomidine) and group RD3 (TAP block with ropivacaine and 2 µg/kg dexmedetomidine). TAP blocks were performed post-operatively. The four groups all received patient-controlled intravenous analgesia (PCIA) after the operation. The numerical rating scale (NRS) as well as the Ramsay sedation scale (RSS) scores, the first request time for PCIA bolus, oxycodone hydrochloride consumption, the plasma concentration of ropivacaine, the incidence of post-operative complications and adverse events, and patient satisfaction were recorded. Post-operative NRS scores at rest exhibited significant differences between the R group and all the RD groups at 24 h after surgery (P<0.05). Compared with the other groups, the NRS score in the RD3 group was decreased (P<0.05). The RSS scores were higher in all of the RD groups compared with those in the R group at 2 h (P<0.05) and were highest in the RD3 group compared with those in all other groups at 4 h (P<0.05). The first request time for PCIA was significantly longer in the RD3 group compared with that in the RD2, RD1 and R groups (510.47±102.67, 595.47±100.11, 682.43±104.46 and 776.42±143.91 min, respectively; P<0.05). Cumulative opioid consumption based on the number of PCIA bolus requested at 24 and 48 h post-operatively indicated that the total number of PCIA boluses was significantly lower in the RD groups compared with those in the R group at 24 and 48 h (P<0.05). The ropivacaine concentration did not differ among the four groups. There was no significant difference between groups with respect to post-operative nausea and vomiting, bradycardia and hypotension; however, all RD groups had a higher patient satisfaction than group R (P<0.05). Compared with that in the other groups, the duration of post-anesthesia care unit stay in group RD3 was relatively longer due to excessive sedation (P<0.05). In conclusion, TAP blockade using 0.5-2 µg/kg dexmedetomidine combined with 0.3% ropivacaine is a safe and effective treatment for analgesia in laparotomy procedures for gynecologic malignancies. The study was registered in the Chinese Clinical Trial Registry (CHICTR; www.chictr.org.cn) on January 15th, 2019 (registration no. ChiCTR1900020995).

Contribution of Regional anaesthesia on health economics: cost effectiveness of preemptive TAP block in Laparoscopic cholecystectomy

Objective: Regional anaesthesia can play a vital role as a supplement of general anaesthesia inlaparoscopic cholecystectomy surgery. In this study we postulated that preemptive bilateral dualtransversus abdominis plane (BD - TAP) block has the potential to reduce the requirement of volatileanaesthetic, muscle relaxant, postoperative opioid demand and shortening of hospital stay in laparoscopiccholecystectomy surgery, ultimately total cost. Method: Total 40 patients ASA I - II undergoing laparoscopic cholecystectomy surgery were randomlyassigned into two equal groups of 20 patients each. All patients received preemptive IV Paracetamol (15mg/kg), IV Diclofenac (1 mg/kg) and BD - TAP block. Block was performed with bilateral Subcostal(medial to linea semilunaris) and lateral TAP injection with total 70 ml drug volume. Group A receiveda drug solution containing plain Bupivacaine 15 ml (0.1%), Lidocaine 35ml (1%), Dexamethasone 10mg. Group B received a total 70 ml normal saline injection. Maintenance of anaesthesia was accomplishedwith low flow anaesthesia (0.5 - 1.0 L/min) accompanied by BIS monitoring, maintaining BIS index 45- 55. All patients received Sevoflurane with N2O 60%. Muscle relaxation was guided by TOF monitoringand supplemental dose was adjusted by the TOF counting. Postoperative analgesia was maintainedwith IM pethidine in p.r.n dose and oral paracetamol in regular doses. Total opioid requirement, musclerelaxant and volatile anaesthetic used and duration of postoperative hospital stay were recorded. Result: BD - TAP block reduced the Sevoflurane requirement, group A 5.5 (± 0.05) ml/ hr and group B6.8 (± 0.9) ml/ hr (p &lt; 0.05). It also reduced the requirement of Rocuronium in comparison to controlgroup, group A 49.5 (± 2.85) mg and in group B 58 (± 4.21) mg (p &lt; 0.05). Postoperative pethidinerequirement, group A 135 (± 22.9) mg and group B 375 (± 46) mg (p &lt; 0.05). It also facilitated rapidhospital discharge, group A 1.16 (± 0.5) days and group B 2.03 (± 0.5) days (p &lt; 0.05). Conclusion: In this study it is demonstrated that preemptive (BD - TAP) block in laparoscopiccholecystectomy surgery is associated with reduced requirement of volatile anaesthetic, muscle relaxantand postoperative opioid consumption. It seems that regional anaesthesia has a big contribution inmodern health economics and national health policy should consider this issue. JBSA 2020; 33(1): 3-9

Comparison of Postoperative Analgesia in Patients Undergoing Ileostomy Closure with and Without Dual Transversus Abdominis Plane (TAP) Block – Prospective Randomized Controlled Trial

Comparison of Postoperative Analgesia in Patients Undergoing Ileostomy Closure with and Without Dual Transversus Abdominis Plane (TAP) Block – Prospective Randomized Controlled Trial

Comparison of Postoperative Analgesia in Patients Undergoing Ileostomy Closure with and Without Dual Transversus Abdominis Plane (TAP) Block: A Randomized Controlled Trial.

Background and AimsMultimodal analgesia comprising opioid, paracetamol, and non-steroidal anti-inflammatory drugs is used for managing postoperative surgical pain after ileostomy closure (IC). We investigated the efficacy of unilateral dual transversus abdominis plane (TAP) block to reduce morphine consumption in the first 24 hours along with a reduction in visual analogue score for pain and in postoperative nausea/vomiting.MethodsThis was a single-center, investigator-initiated, prospective, parallel-group, placebo-controlled randomized study involving patients undergoing IC under general anesthesia. We recruited 55 patients in two groups: 28 in a TAP group and 27 in a placebo group. The TAP group patients received 30 mL of 0.375% bupivacaine: 15 mL by a posterior TAP approach and 15 mL by a subcostal approach using ultrasonography. Patients in the placebo group received 30 mL normal saline (placebo) using the same approaches. Blocks were administered at the end of surgery before extubation. To monitor for the primary outcome—24-hour morphine consumption for both groups—patients were transferred to a high-dependency unit. The secondary outcome was to compare postoperative nausea/vomiting in both groups.ResultsThe demographic data, gender distribution, ASA physical status, duration of surgery, and time of first morphine dose was comparable in both groups. The 24-hour morphine consumption was 3.29±2.78 mg and 9.23±2.94 mg for the TAP and placebo groups, respectively, which was statistically significant (P=0.001).ConclusionDual TAP block reduces opioid consumption in the first 24 hours after an IC and can facilitate early recovery with less adverse effects seen than with opioids and NSAIDs.

Comparative efficacy of postoperative analgesia between ultrasound-guided dual transversus abdominis plane and Ilioinguinal/Iliohypogastric nerve blocks for open inguinal hernia repair: An open label prospective randomised comparative clinical trial.

Background and Aims:Transversus abdominis plane (TAP) and Ilioinguinal/Iliohypogastric (IL/IH) nerve blocks have been advocated in reducing postoperative pain and additional analgesic requirement following lower abdominal surgeries with varied effect. The aim of this study was to determine post-operative analgesic efficacy by comparing dual TAP [combining TAP and IL/IH nerve blocks] and IL/IH nerve block alone for open inguinal hernia repair.Methods:Two hundred patients undergoing elective primary unilateral open inguinal hernia repair with a mesh were included in to this trial. Ultrasound-guided dual TAP (D-TAP Group) or IL/IH (IL/IH Group) nerve block were administered to patients following subarachnoid block according to their group allocation, with 0.5% ropivacaine. Post operatively patients were monitored for visual analogue scale (VAS) scores at rest (at 4, 12, 24 and 48h) and during movement (at 24, 48 h, 3 and 6 months). Pain scores at 3 and 6 months were assessed by telephonic interview, using the DN4 questionnaire for neuropathic pain. The statistics was obtained using Chi-square test for proportions in qualitative data and student's unpaired t test for quantitative data. P value <0.05 was considered significant.Results:The pain scores at rest (VAS-R) were significantly lower at 12 hours and 24 hours (P < 0.001) in D-TAP group, while pain scores at movement were significantly lower (P < 0.001) in D-TAP group at 24 and 48 hours compared to IL/IH group. The mean time required for first rescue analgesic was longer in D-TAP group (5.590 ± 2.386 hr) in comparison to IL/IH group (3.1053 ± 1.1822h).Conclusion:Ultrasound-guided dual TAP block provides more effective post-operative analgesia in open inguinal hernia repair.

Effect of Adding Dexmedetomidine to Ropivacaine on Ultrasound-Guided Dual Transversus Abdominis Plane Block after Gastrectomy

ObjectivesTransversus abdominis plane (TAP) block is an analgesic technique. Adding dexmedetomidine can enhance regional anesthesia. This study’s aim was to evaluate whether dexmedetomidine prolonged analgesic time of TAP block after gastrectomy. MethodsPatients scheduled for gastrectomy were randomly assigned to receive a TAP block with saline (group S), ropivacaine (group R), or ropivacaine and dexmedetomidine (group RD). Visual analogue scale (VAS) scores, postoperative nausea and vomiting (PONV) scores, sedation scores, tramadol consumption, ropivacaine concentration, and Quality of Recovery Questionnaire 40 (QoR-40) were recorded. ResultsPatients in group R and group RD had lower VAS scores 2, 4, 12, and 24 h after surgery compared with group S (P < 0.05). PONV scores were lower in group R and group RD compared with group S after 2, 12, 24, and 36 h (P < 0.05). Patients in group R and group RD required less tramadol and had better QoR-40 scores than those in group S (P < 0.05). The aforementioned variables and ropivacaine concentrations did not differ between group R and group RD (P > 0.05). Sedation scores were similar between three groups (P > 0.05). ConclusionsTAP block can provide analgesia and improve the quality of recovery. Adding dexmedetomidine does not significantly improve the quality or duration of TAP block.

A randomised controlled trial of bilateral dual transversus abdominis plane blockade for laparoscopic appendicectomy.

We investigated the effects of pre-operative ultrasound-guided bilateral dual transversus abdominis plane blocks on pain when sitting up and pain at rest after laparoscopic appendicectomy. We allocated 28 participants to injection with 60 ml ropivacaine 0.375% and 28 participants to 60 ml isotonic saline. The median (IQR [range]) cumulative pain scores during the first 12 postoperative hours were less after ropivacaine than saline (maximum 120): on sitting, 34 (19-46 [0-59]) vs 50 (30-59 [0-97]), respectively, p = 0.009; and at rest, 25 (10-33 [0-49]) vs 31 (24-43 [0-72]), respectively, p = 0.035. There were no differences in morphine consumption, nausea, vomiting, time in recovery or time to walk.

Injectate spread following ultrasound-guided lateral to medial approach for dual transversus abdominis plane blocks.

Bilateral dual transversus abdominis plane (BD-TAP) injections were devised to cover the T7-8 and L1 dermatomes, which are usually spared with classical and mid-axillary TAP injections. The purpose of this study was to delineate the vertical and lateral extent of injectate spread following a lateral to medial approach for TAP injections in embalmed cadavers. Ultrasound-guided subcostal and lateral TAP injections were performed on nine embalmed cadavers using 30 ml of 0.5% methylcellulose (20 ml for subcostal and 10 ml for lateral injections) with a 12-cm Tuohy needle in the first six cadavers (nine hemi-abdomens). Vertical extent and the medial to lateral extent of the dye spread were recorded after dissections of the abdominal wall. In a pilot of three cadavers not receiving TAP injections, anatomical impediments to proximal injectate spread were explored separately. The vertical spread of injectate was T7-L1 (n = 2/9), T8-L1 (n = 5/9) and T9-L1 (n = 2/9). None of the TAP injections extended beyond the mid-axillary line. No anatomical impediments for the flow of injectate to the T7 or T8 intercostal nerves were found at the level of the interdigitations of the transversus abdominis muscle and diaphragm. A lateral to medial approach for TAP injection resulted in spread of the injectate ranging from T7/8-L1 dermatomes in the majority of the hemi-abdomens. Subcostal and lateral TAP injections do not cover the lateral cutaneous branches of the segmental nerves.

Bilateral dual transversus abdominis plane block providing surgical anaesthesia for abdominal wall surgery

Bilateral dual transversus abdominis plane block providing surgical anaesthesia for abdominal wall surgery

Is Pulmonary Function Affected by Bilateral Dual Transversus Abdominis Plane Block? A Randomized, Placebo-Controlled, Double-Blind, Crossover Pilot Study in Healthy Male Volunteers

Transversus abdominis plane (TAP) blocks have been shown to reduce postoperative pain after various abdominal surgical procedures in several studies. The motor nerves of the abdominal wall are located in the same plane as the sensory nerves affected by the TAP block. The aim of this study was to examine whether the application of an ultrasound-guided TAP block would affect the muscles of the anterior abdominal wall with respect to their function as accessory respiratory muscles and hence pulmonary function. Twelve healthy male volunteers were included in a randomized, double-blind, crossover study. Primary outcome measure was change in forced expiratory volume in 1 sec (FEV1) after the bilateral dual injection of either 4 × 15 mL of 0.25% bupivacaine or saline. Secondary outcome measures included forced vital capacity, maximum expiratory pressure, and a number of frontal abdominal quadrants anesthetized. Change in FEV1 following the administration of bupivacaine showed a mean increase of 15 (SEM, 45.5) mL compared with the saline block, which showed a mean increase in FEV1 of 34 (SEM, 57.4) mL (P = 0.62). Similar results were obtained for forced vital capacity and maximum expiratory pressure. Abdominal quadrants were inconsistently anesthetized following administration of bupivacaine blocks. The administration of ultrasound-guided bilateral dual TAP blocks does not result in clinically relevant or statistically significant changes in the pulmonary function in healthy male subjects.

Ultrasound-guided bilateral dual transversus abdominis plane block: a new four-point approach

We describe a new ultrasound-guided bilateral dual transversus abdominis plane block. Our hypothesis was that we could anaesthetize both the upper (Th6-Th9) and the lower (Th10-Th12) abdominal wall bilaterally using a four-point single-shot technique to provide effective post-operative analgesia. A prospective cohort of 25 recovery room patients was included. They had undergone major open or laparoscopic abdominal surgery under general anaesthesia and had severe post-operative pain. The blocks were conducted using a high-frequency linear transducer and a 22 G, 80-mm-long needle. The needle was inserted in-plane from medial to lateral for each injection. Fifteen millilitres of bupivacaine 2.5 mg/ml was injected at each of the four sites. Block performance took on average 16 min (range 10-20 min). The 25 patients reported a reduction of their maximum pain (visual analogue scale 0-10) from a mean of 8.2 to a mean of 2.2 10 min after block performance (P<0.001). They were discharged from the post-anaesthesia care unit after an average of 34 min. Twenty-one patients (84%) did not require any i.v. opioids in the following 6 h. Sixteen patients (64%) were mobilized within 6 h after the block. Data were similar irrespective of open or laparoscopic surgery (P=0.68). This new four-point single-shot technique was effective in decreasing severe pain after a major abdominal surgery. The block, although short-lived, facilitated discharge from the post-anaesthesia care unit, few patients required opioids on the day of surgery and mobilization was improved.