Transversus Research Articles

Ultrasound imaging of core muscles activity in multiparous women with vaginal laxity: a cross-sectional study

Vaginal laxity (VL) is a common condition among multiparous women, especially those who have delivered vaginally. Since pelvic floor muscles (PFMs) work synergistically with other core muscles, physical therapy protocols that aim to treat VL should train the PFMs in combination with other core muscles. To investigate the activity of core muscles in multiparous women with and without VL, and its relation to sexual function. An observational, cross-sectional study. The study included 100 multiparous women, who were divided into two groups according to their scores on the vaginal laxity questionnaire (VLQ). Women who scored between 1 and 3 on the VLQ were categorized as having VL (n = 48), while those who scored between 5 and 7 were placed in the control group (n = 52). The primary outcomes were PFM displacement, diaphragmatic excursion, transversus abdominis activation ratio, and lumbar multifidus thickness measured by ultrasound imaging. The secondary outcome was sexual functioning, evaluated using the Arabic female sexual function index (ArFSFI). The VL group had significantly lower PFM displacement (mean difference (MD) − 0.42; 95% confidence interval (CI) − 0.49 to − 0.33; p = 0.001), diaphragmatic excursion (MD − 2.75; 95% CI − 2.95 to − 2.55; p = 0.001), lumbar multifidus thickness (MD − 10.08; 95% CI − 14.32 to − 5.82; p = 0.02), and ArFSFI scores (MD − 9.2; 95% CI − 10.59 to − 7.81; p = 0.001) in comparison to the control group (p < 0.05). Nevertheless, the transversus abdominis activation ratio demonstrated no significant difference between the two groups (MD 0.06; 95% CI − 0.05 to 0.17; p = 0.33). Multiparous women with VL had significantly lower PFM displacement, diaphragmatic excursion, lumbar multifidus thickness, and sexual function index scores than women in the control group. The only exception was transversus abdominis activation, which did not differ significantly between the VL and control groups.

Postoperative bleeding after complex abdominal wall reconstruction: A post hoc analysis of a randomized clinical trial

BackgroundAbdominal wall reconstruction requires extensive dissection of the abdominal wall, exposure of the retroperitoneum, and aggressive chemoprophylaxis to reduce the risk of thromboembolic complications. The need for early anticoagulation puts patients at risk for bleeding. We aimed to quantify postoperative blood loss, incidence of transfusion and reoperation, and associated risk factors in patients undergoing complex abdominal wall reconstruction. MethodsAll patients underwent a posterior component separation with transversus abdominis release and placement of retromuscular mesh for ventral hernias <20 cm wide and were enrolled in a clinical trial assessing the utility of trans-fascial mesh fixation. A post hoc analysis was performed to quantify postoperative hemoglobin drop, blood transfusions, and procedural interventions for ongoing bleeding during the first 30 postoperative days. Multivariate logistic regression was used to identify predictors of transfusion. ResultsIn 325 patients, hemoglobin decreased by 3.61 (±1.58) g/dL postoperatively. Transfusion incidence was 9.5% (n = 31), and 3.1% (n = 10) required a surgical intervention for bleeding. Initiation of therapeutic anticoagulation postoperatively resulted in a higher likelihood of requiring surgical intervention for bleeding (odds ratio 10.4 [95% confidence interval 2.75–43.8], P < .01). Use of perioperative therapeutic anticoagulation was associated with higher rates of transfusion (odds ratio 3.51 [95% confidence interval 1.34–8.53], P < .01). Neither intraoperative blood loss nor operative times were associated with an increased transfusion requirement or need for operative intervention. ConclusionPatients undergoing transversus abdominis release are at a high risk of postoperative bleeding that can require transfusion and reoperation. Patients requiring postoperative therapeutic anticoagulation are at particularly high risk.

A Comparison between Core Stability Exercises and Muscle Thickness Using Two Different Activation Maneuvers.

Core stability training is crucial for competitive athletes, individuals who want to improve their health and physical performance, and those undergoing clinical rehabilitation. This study compared the ultrasound (US) muscle thickness of the abdominals and lumbar multifidus (LM) muscles between seven popular trunk stability exercises performed using hollowing and bracing maneuvers. Forty-four healthy young adults, aged between 21 and 32 years, performed a plank, bird dog, beast crawl, dead bug, Pilates tap, bridge, and side planks using the bracing and the hollowing maneuver. The thickness of the transversus abdominis (TrA), internal oblique (IO), and LM muscles was measured simultaneously using two ultrasound machines. Analysis of variance designs indicated that during hollowing, the bird dog and side plank exercises resulted in the greatest increase in the muscle's relative thickness overall. The relative thickness of all muscles was significantly greater (p < 0.001) during hollowing (22.7 ± 7.80 to 106 ± 24.5% of rest) compared to bracing (18.7 ± 7.40 to 87.1 ± 20.9% of rest). The TrA showed the greatest increase in thickness (p < 0.001) compared to the IO and LM. Additionally, the IO had a greater increase in thickness (p < 0.001) than the LM. In conclusion, our findings indicate that the bird dog and side plank exercises, when performed with hollowing, showed the most significant total muscle thickness increase. Notably, the hollowing maneuver enhances the thickness of the TrA, IO, and LM muscles more than the bracing maneuver. This contributes to the discussion on optimal strategies for dynamic core stabilization.

Decreasing Perioperative Opiate Use During Pancreaticoduodenectomy Using Transversus Abdominus Plane Blocks: A Review of the Literature.

Pancreatoduodenectomy is a highly complex surgical procedure associated with high postoperative morbidity and mortality. Treatment of postoperative pain is crucial to preventing chronic pain and further complications. Opioids are the leading treatment modality for acute postoperative pain for all surgical procedures in the US, contributing to the opioid epidemic, a crisis causing death and lifelong impairment in many patients. Multimodal analgesia techniques, such as the transversus abdominis plane (TAP) block, are suggested to reduce perioperative opioid usage. This exploratory literature review aims to investigate the use of TAP block in postoperative pain and opioid use in patients undergoing pancreatoduodenectomy. A search strategy developed from Cochrane best practice recommendations was applied to a comprehensive search of PubMed, Scopus, and PsycINFO databases, yielding three articles of relevance in patients having pancreatic surgery. Previous research demonstrates TAP block efficacy in decreasing opiate consumption after major abdominal surgery; however, there is a paucity of data regarding opioid consumption in pancreatoduodenectomy patients. Research in relation to TAP block analgesia is varied given the variety of approaches, techniques, and timing of the TAP block procedure. Future research should seek to elucidate the role of TAP blocks in reducing postoperative pain and opioid consumption in pancreatoduodenectomy patients.

Laparoscopic assisted versus ultrasound guided transversus abdominis plane block in laparoscopic bariatric surgery: a randomized controlled trial

BackgroundTransversus abdominis plane block (TAPB) guided by laparoscopy and ultrasound showed promise in enhancing the multimodal analgesic approach following several abdominal procedures. This study aimed to compare the efficacy and safety between Laparoscopic (LAP) TAP block (LTAP) and ultrasound-guided TAP block (UTAP) block in patients undergoing LAP bariatric surgery.Patients and methodsThis non-inferiority randomized controlled single-blind study was conducted on 120 patients with obesity scheduled for LAP bariatric surgeries. Patients were allocated into two equal groups: LTAP and UTAP, administered with 20 mL of 0.25% bupivacaine on each side.ResultsThere was no statistically significant difference in the total morphine consumption, Visual Analogue Scale (VAS) score at all times of measurements, and time to the first rescue analgesia (p > .05) between both groups. The duration of anesthesia and duration of block performance were significantly shorter in the LTAP group than in the UTAP group (p < .001). Both groups had comparable post-operative heart rate, mean arterial pressure, adverse effects, and patient satisfaction.ConclusionsIn LAP bariatric surgery, the analgesic effect of LTAP is non-inferior to UTAP, as evidenced by comparable time to first rescue analgesia and total morphine consumption with similar safety blocking through the low incidence of post-operative complications and patient satisfaction.Trial registrationThe study was registered in Pan African Clinical Trials Registry (PACTR) (ID: PACTR202206871825386) on June 29, 2022.

Case Series of Multicontact Peripheral Nerve Stimulation in the Transversus Abdominis Plane for Chronic Abdominal Wall Pain

ObjectivesManaging abdominal pain can be difficult. This is due to the nonspecific nature of the pain, the multiple etiologies, and the different mechanisms underlying this type of pain. Abdominal wall pain in particular poses its own challenges. Traditionally, chronic abdominal wall pain has been managed with nonopioid analgesics, and in severe cases, opioid therapy has been considered. For patients with chronic abdominal wall pain refractory to medication management, peripheral nerve blocks and spinal cord stimulation also have been trialed with some success. In this study, we present a case series in patients with chronic abdominal wall pain who were treated with a multicontact peripheral nerve stimulation (PNS) system in the transversus abdominis plane (TAP). Materials and MethodsThis was a single-center, retrospective case series. Data were included from adults with chronic abdominal wall pain whose symptoms were refractory to standard medical management and who underwent a multicontact PNS system placement in the TAP. ResultsFour patients met the inclusion criteria. All four patients underwent a multicontact PNS trial lead placement in the TAP. One patient reported no benefit from the trial. The remaining three patients underwent a permanent multicontact PNS system placement in the TAP. ConclusionsIn patients with chronic abdominal wall pain whose symptoms are refractory to conservative medical management, PNS may be an alternative treatment option. As the use of PNS for chronic abdominal wall pain and other fascial planes continues to develop, additional research is necessary to determine optimal placements and specific stimulation parameters.

Optical Trocar Access for Retroperitoneal Robotic-Assisted Pyeloplasty in Children with Ureteropelvic Junction Obstruction.

Purpose: Retroperitoneal robotic-assisted pyeloplasty (ret-RAP) for ureteropelvic junction obstruction (UPJO) requires a larger retroperitoneal space (RS) to maintain specified distances between robotic (da Vinci) trocars and between trocars and the region of interest. A modified closed technique (MOT) and conventional closed technique (COT) were compared for creating an adequate RS with optical trocars. Methods: RS access in children with UPJO who underwent ret-RAP (n = 30) was MOT (n = 15) and COT (n = 15). All patients were positioned laterally. For MOT, a 5 mm optical trocar was inserted at the angle formed between the 12th rib and the erector spinae muscles. As the trocar was advanced under direct vision, it pierced the superficial subcutaneous layer, Scarpa's fascia, lumbar fascia, internal/external oblique and transversus abdominalis muscles, and the posterior renal fascia. Once in the RS, the tip of the scope was used for blunt dissection of perirenal fat, the tip was withdrawn until it was outside the perirenal fascia, and used to dissect toward the anterior abdomen in the pararenal fat layer. Results: Ages and weights at ret-RAP were similar (MOT: 5.6 ± 1.8 years versus COT: 7.8 ± 4.6 years; MOT: 20.6 ± 10.1 kg versus COT: 27.6 ± 13.9 kg). Times for RS access were similar (MOT: 1.6 ± 0.5 minutes versus COT: 1.9 ± 0.7 minutes), but RS expansion was significantly quicker in MOT (32.3 ± 8.7 minutes versus 52.0 ± 15.1 minutes; P < .001). Peritoneal injury caused carbon dioxide leakage in 4 of 15 COT cases and 0 of 15 MOT cases. Conclusion: RS expansion with MOT was safer because there were no peritoneal injuries and MOT was quicker than COT.

Assessment of Lateral Abdominal Muscle Activation Asymmetry via M-mode Ultrasonography.

This study aimed to evaluate the asymmetry in the lateral abdominal muscles (LAMs) expressed as tissue deformation index asymmetry (aTDI) with the use of M-mode ultrasonography. The muscles of interest were the transversus abdominis, internal oblique, and external oblique. This is a cohort of 126 healthy subjects who participated in the study. Measurements were taken by two raters, blinded to the aim of the study. M-mode ultrasounds with a measurement frequency of 5 MHz were utilized to record the postural response of LAMs to external perturbation in the form of rapid arm abduction with load, and individual aTDI values for each muscle were calculated. The aTDI values from deep to superficial LAMs were 78.28% for transversus abdominis, 55.68% for internal oblique, and 44.80% for external oblique. Only the aTDI for transversus abdominis results differed significantly from those of the other LAMs (P<0.05). LAM asymmetry values exhibit the following gradient: transversus abdominis >internal oblique >external oblique. Specifically, only transversus abdominis demonstrates noteworthy asymmetry in postural activity. This observation contributes to the literature by indicating that transversus abdominis asymmetry may serve as a marker for assessing the variability in motor control of the deep abdominal musculature. The dominance of transversus abdominis (TrA) asymmetric activity underlines the importance of personalized approaches for patients with lumbopelvic disorders or for athletes seeking to enhance performance.

Efficacy of Landmark-Guided Transverse Abdominis Plane (LTAP) Block in Pediatric Patients Undergoing Laparoscopic Appendectomy.

Optimizing perioperative analgesia in patients undergoing abdominal surgery remains a challenge given the side effects of narcotics and the potential for abuse. While transversus abdominis plane block has been shown to improve clinical outcomes, such as decreased opioid consumption and pain scores among adult patients, there is limited data regarding its efficacy for pediatric patients. This study evaluates efficacy amongst pediatric patients undergoing landmark-guided transversus abdominis plane (LTAP) during laparoscopic appendectomy. A retrospective chart review of patients, ages 0-18years old, who underwent laparoscopic appendectomy for uncomplicated appendicitis at a single institution from January 2021 to December 2022 was conducted. Pearson's chi-square test or Fisher's exact test and Welch's t test were used to assess differences between the two cohorts for categorical and continuous variables, respectively. Results are statistically significant at P < .05. Of the 90 patients who met inclusion criteria, 40% (n = 36) underwent LTAP block. Those with LTAP block had a shorter average operative time than those without LTAP block (.6 vs .7 hours; P = .009). Similarly, patients with LTAP block had a shorter average time to discharge (4.1 vs 11.0h; P = .039). There were no other statistically significant differences in postoperative outcomes including narcotic use between both cohorts. Landmark-guided transversus abdominis plane blocks did not increase operative times yet reduced time to discharge for pediatric patients who underwent laparoscopic appendectomy at our institution. Larger studies are needed to evaluate the relationship between LTAP administration and postoperative narcotic consumption to make clinical recommendations.

Two-meshes approach in posterior component separation with transversus abdominis release: the IMPACT study (Italian Multicentric Posterior-separation Abdominal Complex hernia Transversus-release).

Surgical management of large ventral hernias (VH) has remained a challenge. Various techniques like anterior component separation and posterior component separation (PCS) with transversus abdominis release (TAR) have been employed. Despite the initial success, the long-term efficacy of TAR is not yet comprehensively studied. Authors aimed to investigate the early-, medium-, and long-term outcomes and health-related quality of life (QoL) in patients treated with PCS and TAR. This multicenter retrospective study analyzed data of 308 patients who underwent open PCS with TAR for primary or recurrent complex abdominal hernias between 2015 and 2020. The primary endpoint was the rate of hernia recurrence (HR) and mesh bulging (MB) at 3, 6, 12, 24, and 36months. Secondary outcomes included surgical site events and QoL, assessed using EuraHS-QoL score. The average follow-up was 38.3 ± 12.7months. The overall HR rate was 3.5% and the MB rate was 4.7%. Most of the recurrences were detected by clinical and ultrasound examination. QoL metrics showed improvement post-surgery. This study supports the long-term efficacy of PCS with TAR in the treatment of large and complex VH, with a low recurrence rate and an improvement in QoL. Further research is needed for a more in-depth understanding of these outcomes and the factors affecting them.

The automatic activity of abdominal muscles during stable and unstable standing postural tasks in older adults with and without low back pain- A cross-sectional study

BackgroundThe postural control and abdominal muscles’ automatic activity were found to be impaired in subjects with low back pain (LBP) during static activities. However, the studies are predominantly conducted on younger adults and a limited number of studies have evaluated abdominal muscles’ automatic activity during dynamic standing activities in subjects with LBP. The present study investigated the automatic activity of abdominal muscles during stable and unstable standing postural tasks in older adults with and without LBP.MethodsTwenty subjects with and 20 subjects without LBP were included. The thickness of the transversus abdominis (TrA), internal oblique (IO), and external oblique (EO) muscles was measured during rest (in supine), static, and dynamic standing postural tasks. To estimate automatic muscle activity, each muscle’s thickness during a standing task was normalized to its thickness during the rest. Standing postural tasks were performed using the Biodex Balance System.ResultsThe mixed-model analysis of variance revealed that task dynamicity significantly affected thickness change only in the TrA muscle (P = 0.02), but the main effect for the group and the interaction were not significantly different (P > 0.05). There were no significant main effects of the group, task dynamicity, or their interaction for the IO and EO muscles (P > 0.05). During dynamic standing, only the TrA muscle in the control group showed greater thickness changes than during the static standing task (P < 0.05).ConclusionsStanding on a dynamic level increased the automatic activity of the TrA muscle in participants without LBP compared to standing on a static level. Further research is required to investigate the effects of TrA muscle training during standing on dynamic surfaces for the treatment of older adults with LBP.

Peripheral nerve blocks for analgesia following cesarean delivery A narrative review.

Spinal and epidural blocks are commonly employed for pain relief during and following cesarean section. Intrathecal morphine (ITM) has been the gold standard for the same for many years. In recent times, many peripheral nerve blocks (PNBs) have been tried for postoperative analgesia following cesarean delivery (PACD). This article has reviewed the common PNBs used for PACD. The role of PNBs along with ITM has been studied and the current best strategy for PACD has also been explored. Currently, Ilio-inguinal nerve and anterior transversus abdominis plane block in conjunction with intrathecal morphine have been found to be the most effective strategy, providing lower rest pain at 6 hours as compared to ITM alone. In patients not receiving intrathecal morphine, recommended PNBs are lateral transversus abdominis plane block, single shot local anesthetic wound infiltration, or continuous wound infiltration with catheter below rectus fascia. PNBs are recommended for PACD. They have an opioid-sparing effect and are devoid of adverse effects associated with central neuraxial blocks such as hypotension, bradycardia, and urine retention. However, caution must be observed with PNBs for possible local anesthetic toxicity due to the large volumes of drug required.

Transversus Abdominis Plane Block versus Epidural Anesthesia for Pain Management Post-Caesarean Delivery: A Pilot Study.

Effective post-operative analgesia profoundly influences patient recovery and outcomes after caesarean delivery. The Transversus Abdominis Plane (TAP) block represents a potential alternative, potentially offering greater effectiveness than epidural analgesia while causing fewer adverse effects. To assess if the abdominal transverse block provides superior postoperative pain relief in patients undergoing caesarean delivery compared to epidural analgesia. Participants were divided into parallel groups: an experimental group receiving TAP block (n=25) and a control group receiving epidural analgesia (n=24). All patients received a 10 mg dose of hyoscine at the end of the surgery. Experimental Group received a total of 20 mL of 0.2% ropivacaine. In Epidural group received 0.2% ropivacaine at 4 mL/h for 24 hours. All participants were administered combined with neuroaxial block anesthesia. The patients selected for epidural analgesia received the mentioned dose, while the other group block had the epidural catheter removed after the cesarean section. The primary outcome was post-caesarean pain, evaluated using the Visual Analog Scale (VAS) at four intervals (0, 6, 12, and 24 hours). Also, surgical bleeding and residual motor were evaluated. VAS pain scores between the groups were compared using the Friedman test and Generalized Linear Model (GLM) for non-normally distributed data. The effect size was estimated with Eta Square ([Formula: see text]), considering values ≥0.38 as indicative of large effects. A two-tailed p-value < 0.05 was deemed statistically significant. Statistically significant differences in pain scores were noted at 0 and 6 hours post-surgery (p<0.01). The TAP block group reported lower pain scores at 0 hours (mean=0.04) and 6 hours (mean=1.16) compared to the epidural group, reflecting a substantial effect size. The TAP block proves advantageous in mitigating postoperative pain for women post-caesarean delivery, particularly in the initial 6 postpartum hours. This relief promotes early mother-infant bonding and facilitates breastfeeding.

Clinical Effectiveness of Transversus Abdominis Plane (TAP) Block versus Local Anesthesia Wound Infiltration for Postoperative Pain Relief After Laparoscopic Appendicectomy in Children: A Study Protocol for a Multicenter Double-Blind Randomized Controlled Phase III Trial.

Postoperative pain relief after laparoscopic appendicectomy is a key determinant of early rehabilitation in children. Recent guidelines recommend performing either a transversus abdominis plane (TAP) block or local anesthesia (LA) wound infiltration as part of multimodal postoperative analgesia after appendectomy. To date, the clinical effectiveness of TAP block versus LA wound infiltration has never been compared. The hypothesis of this study is that the TAP block may provide a greater opioid-sparing effect after laparoscopic appendicectomy in children than LA wound infiltration. We designed a multicenter double-blind randomized controlled phase III trial and aim to include 110 children who undergo laparoscopic appendicectomy. Children are randomized to receive either TAP block (TAP group) or LA wound infiltration (infiltration group). Multimodal analgesia is standardized in the two groups using the same protocol, which includes the stepwise prescription of paracetamol, phloroglucinol, ketoprofene, and nalbuphine according to the hetero-evaluation of pain performed by the nurses who were blinded to the treatment allocated using the validated FLACC scale. The primary outcome is the total dose of nalbuphine administered within 24 hours after surgery. No study has specifically compared the clinical effectiveness of TAP block versus LA wound infiltration for postoperative pain relief after laparoscopic appendectomy in children. This paper describes the protocol for a randomized trial that addresses this issue. The results of this trial will be useful for editing guidelines with a higher level of evidence on this topic.

Intraperitoneal instillation versus port-site infiltration or subcostal transversus abdominis plane block for post-operative analgesia following laparoscopic cholecystectomy

Background Although pain after laparoscopic surgery is less compared with open cholecystectomy, pain management in the first 24 to 72 h in the postoperative period is tricky and most patients complain of pain with cough, breathing and mobilization during the initial hours. The aim of this study was to evaluate the most efficacious route of analgesia in patients following laparoscopic cholecystectomy by comparing port-site wound infiltration, intraperitoneal infiltration and subcostal transversus abdominis plane block in providing post-operative analgesia following laparoscopic cholecystectomy. Methods This was an observational study performed on patients who underwent elective laparoscopic cholecystectomy at a tertiary care hospital in Mangalore. Group A received bupivacaine instilled in gallbladder fossa after removal of gall bladder before closure. Group B received Bupivacaine as an infiltration into the skin incision site (fascia, muscle, preperitoneal space) at each of the four port sites based on the length of the skin incision before closure. Group C received bupivacaine as subcostal transversus abdominis plane block under ultrasound guidance immediately postclosure. Collected data was entered in Microsoft Excel 2007 and analyzed using SPSS version 22.0 to find frequency, Mean and SD. Significance was assessed using Kruskal–Wallis test, χ 2 test and ANOVA for repeated measures. Results Hemodynamic parameters, i.e. the heart rate and mean arterial pressure were comparable at the end of 2 h and 4 h. At 6 and 8 h postoperatively however, visual analog scale was significantly better in group C compared with groups A and B. Time until the first analgesic request in group C was 359.35±45.55 min which was significantly lesser than the other two groups. Only three patients from group B had shoulder tip pain which was not seen in the other two groups. Conclusion Infiltration of bupivacaine at port sites is helpful in providing effective analgesia for upto 2 h post operatively whereas intraperitoneal instillation is both effective at meeting analgesic requirements as well as preventing shoulder tip pain. However, the substantial finding of our study is in providing further evidence to existing data that Subcostal transversus abdominis plane block can produce effective analgesia for laparoscopic cholecystectomy, effectively reduces analgesic requirement, and ensures faster recovery.

The impact of transversus abdominus plane (TAP) blocks for total laparoscopic hysterectomy on postoperative pain and recovery time: a retrospective analysis

The impact of transversus abdominus plane (TAP) blocks for total laparoscopic hysterectomy on postoperative pain and recovery time: a retrospective analysis

The effect of upper transabdominal plane block on diaphragm thickness in adult patients after laparoscopic cholecystectomy operation.

In this prospective and observational study, our objective was to examine the impact of subcostal transversus abdominis plane (SubTAP) block, along with intravenous analgesia techniques, on diaphragm thickness and post-operative pain following laparoscopic cholecystectomy. This study examined laparoscopic cholecystectomy patients aged 18-60 years with an American Society of Anesthesiologist score of 1-2. This study divided patients into Group 1 for SubTAP block and Group 2 for intravenous analgesia. This study had 67 patients, at least 30 from each group. Thus, diaphragm thicknesses and Visual Analogue Scale (VAS) values were compared between regional anaesthesia and intravenous analgesia groups. Pre-operative data showed no statistically significant changes between the groups, although post-extubation inspiratory thickness was closer to baseline in Group 1 patients who received regional block. The groups had different outcomes after extubation and at the post-operative 30th min (P = 0.028 and P = 0.001, respectively). There was also a significant difference in post-operative oxygen saturation and VAS scores (P = 0.001). Our receiver operating characteristic analysis determined that the threshold values for VAS parameters of 2 or 3 were 0.28 cm in inspiration, 0.18 cm in expiration and 1.29 as i/e ratio. Significant discomfort was defined as diaphragm parameter values below these limits. We found that the earlier return of diaphragmatic functions to baseline was associated with diaphragm thickness. According to the measurements made in the post-operative care unit, the regional block group effectively prevented the loss of diaphragm function.

Open transversus abdominis release in incisional hernia repair: technical limits and solutions.

Incisional hernias with a defect width of more than10cm are considered complex. The European Hernia Society guidelines recommend that such hernias should only be repaired by surgeons with experience of component separation. The standard component separation technique now is posterior component separation with transversus abdominis release (PCSTAR). Questions are raised about the limits of this technique. A literature search of publications on PCSTAR was performed for any references to the limits of this technique in open incisional hernia repair. We found 26 publications relevant to answer this research questions. The standard PCSTAR can generally be used for a defect width of up to 15-17cm. For defects greater than 17cm problems must be expected with procedural tasks involving closure of the posterior layer and anterior fascia. No data are available in the literature on the bridging rate for the posterior layer. However, our own experiences show that gaps (holes) occur in the very thin peritoneum/fascia transversalis during dissection and these must be carefully closed. Furthermore, bridging with an absorbable synthetic mesh is needed not so rarely. Closure of the anterior fascia is successful in 81.0-97.2% of cases. In addition to a further mesh for anterior fascial closure, the hernia sac bound with multiple, accordion-like stitches can also be used. For a defect width greater than 17cm, the limits of PCSTAR become increasingly evident and can be overcome through special technical solutions for closure of the posterior layer and the anterior fascia.

Can surgeons accurately identify mesh type when interpreting computed tomography scans after ventral hernia repair?

Recurrent ventral hernia repair can be challenging due to scarred tissue planes and the increasing complexity of disease related to multiple recurrences. Given the challenges of acquiring complete and accurate prior operative reports, surgeons often rely on computed tomography (CT) scans to obtain information and plan for re-operation. Still, the contribution of CT scans and the ability of surgeons to interpret them is controversial. Previously, we examined the ability of surgeons to determine prior operative techniques based on CT scans. Here, we assessed the accuracy of expert abdominal wall reconstruction (AWR) surgeons in identifying the type of prior mesh using CT imaging. A total of 22 highly experienced AWR surgeons were asked to evaluate 21 CT scans of patients who had undergone open ventral hernia repair with bilateral transversus abdominis release utilizing mesh. The surgeons were required to identify the mesh type from a multiple-choice selection. Additionally, negative controls (patients without a history of prior laparotomy) and positive controls (patients with laparotomy but no ventral hernia repair) were incorporated. The accuracy of the surgeons and interrater reliability was calculated. The accuracy rate of the surgeons in correctly identifying the mesh type was 46%, with heavy-weight synthetic mesh (HWSM) being identified only 35.4% of the time, Strattice mesh and medium-weight synthetic mesh (MWSM) were identified at 46.3%, and 51.8%, respectively. The interrater reliability analysis found a moderate level of agreement 0.428 (95% CI 0.356-0.503), and the repeatability measure was poor-0.053 (95% CI 0-0.119); this indicates that surgeons cannot reliably replicate the identification process. Surgeons' ability to accurately identify the type of previous mesh using CT scans is poor. This study underscores the importance of documenting the type of mesh used in the operative report and the need for standardized operative notes to improve the accuracy and consistency of documentation.

Impact of a transversus abdominis plane block with low-dose magnesium sulphate coupled to bupivacaine on postoperative pain after laparoscopic cholecystectomy: A randomized trial

ObjectivesThe subcostal transversus abdominis plane (STAP) block has recently been included in the enhanced recovery after surgery (ERAS) protocol for laparoscopic cholecystectomy (LC). In our study on STAP for LC, we compared the effectiveness of adding low-dose magnesium sulphate (MgSO4) to bupivacaine versus using bupivacaine alone. MgSO4 was hypothesized to enhance the analgesic effects of bupivacaine and therefore aid in the recovery process. MethodsSixty patients, aged 18–65 years, ASA I–II, undergoing LC, were randomly assigned to receive bilateral STAP 15 min before skin incision with 20 ml bupivacaine 0.25 % and either 150 mg MgSO4 (BM group) or 1.5 ml normal saline (B group). Pain scores, time to initial analgesic demand, overall analgesic requirement, sedation, emetic episodes, time to get out of bed, and patient satisfaction were recorded for the first 24 h following surgery. The Mann-Whitney U test was used to analyze the non-normally distributed data between groups, while the Chi-square test or Fisher’s exact test was used to test categorical data. ResultsThe BM group had statistically significant but clinically insignificant lower pain scores at rest and during coughing in the post-anesthesia care unit (PACU) (P = 0.005 and P = 0.003), at 1 h (P = 0.005 and P = 0.015), 6 h (P = 0.009 and P = 0.003), 12 h (P = 0.017 and P = 0.001), and 24 h (P = 0.001 and P = 0.001) after surgery compared to the B group. Kaplan–Meier curves for times to the first paracetamol and morphine doses showed significant differences (log-rank test) between the groups (P = 0.001 and P = 0.003, respectively). Additionally, the total doses of paracetamol (P = 0.001) and morphine (P = 0.001) in the BM group were significantly lower than those in the B group during the first 24 h after surgery. Sedation and emetic episodes were identical between the groups. The Patient in the BM group ambulated faster (P = 0.001) and were more satisfied (P = 0.026) than those in the B group. ConclusionsAdding a low-dose (150 mg) of MgSO4 to bupivacaine in the STAP block for LC was associated with improved analgesic outcomes in the first 24 h after surgery. Ethical approvalMedical Ethics Committee of Faculty of Medicine, IRB no: 17,100,622 on November 15, 2016. Trial registrationClinicalTrials.gov (NCT03612947) on August 2, 2018.