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Research Article | Volume 11 Issue 7 (July, 2025) | Pages 379 - 383
Evaluating Transversus Abdominis Plane Block and Rectus Sheath Block in Reducing Postoperative Pain After Umbilical Hernia Repair
 ,
 ,
 ,
1
Associate Professor, Department of Anaesthesia, Narayan Medical College & Hospital, Sasaram, Bihar, India
2
Associate Professor, Department of Surgery, Narayan Medical College & Hospital, Sasaram, Bihar, India
3
Professor, Department of Anaesthesia, Narayan Medical College & Hospital, Sasaram, Bihar, India
4
Junior Resident, Department of Anaesthesia, Narayan Medical College & Hospital, Sasaram, Bihar, India
Under a Creative Commons license
Open Access
Received
June 20, 2025
Revised
June 29, 2025
Accepted
July 3, 2025
Published
July 15, 2025
Abstract

Background: Umbilical hernia repair is associated with significant postoperative pain, which can affect early recovery and prolong hospital stay. Regional anesthesia techniques such as the Transversus Abdominis Plane (TAP) block and Rectus Sheath (RS) block have shown promise in managing postoperative pain. This study aims to compare the effectiveness of TAP block versus RS block in reducing postoperative pain following elective umbilical hernia surgery. Materials and Methods: This prospective randomized study was conducted on 60 patients undergoing elective umbilical hernia repair under general anesthesia. Patients were divided into two groups: Group A (n=30) received ultrasound-guided TAP block, and Group B (n=30) received RS block after induction of anesthesia. Pain was assessed using the Visual Analog Scale (VAS) at 1, 4, 8, 12, and 24 hours postoperatively. Total analgesic consumption within the first 24 hours and time to first rescue analgesia were also recorded. Results: VAS scores were significantly lower in Group A (TAP block) at 4 and 8 hours postoperatively compared to Group B. The mean VAS score at 4 hours was 3.2 ± 0.9 in Group A versus 4.6 ± 1.1 in Group B (p<0.05). The total 24-hour analgesic requirement was also less in the TAP group (110 ± 25 mg tramadol) than in the RS group (150 ± 30 mg tramadol) (p<0.05). Time to first rescue analgesia was longer in Group A (7.8 ± 1.2 hours) compared to Group B (5.4 ± 1.4 hours). Conclusion: TAP block provides superior postoperative analgesia compared to RS block in patients undergoing umbilical hernia repair. It significantly reduces pain scores, delays the requirement for rescue analgesia, and lowers overall analgesic consumption.

Keywords
INTRODUCTION

Umbilical hernia repair is a common surgical procedure frequently associated with moderate to severe postoperative pain, particularly in the early recovery period (1). Effective postoperative pain control is essential not only for improving patient comfort but also for facilitating early ambulation, reducing opioid consumption, and minimizing the risk of complications such as pulmonary dysfunction and delayed discharge (2,3). While systemic analgesics such as opioids and non-steroidal anti-inflammatory drugs (NSAIDs) are widely used, their adverse effects—including nausea, vomiting, sedation, and respiratory depression—highlight the need for alternative pain management strategies (4).

Regional anesthesia techniques have emerged as valuable adjuncts to multimodal analgesia, offering targeted pain relief with fewer systemic side effects. The transversus abdominis plane (TAP) block, which involves injecting local anesthetic between the internal oblique and transversus abdominis muscles, targets the thoracolumbar nerves (T7–L1) supplying the anterior abdominal wall (5). This technique has gained popularity due to its simplicity, safety profile, and efficacy in reducing postoperative pain following lower abdominal surgeries, including hernia repairs and cesarean sections (6).

Similarly, the rectus sheath (RS) block targets the terminal branches of the lower intercostal nerves that run within the rectus abdominis muscle and is particularly effective for midline incisions such as those made in umbilical hernia repair (7). Despite both blocks being employed for abdominal analgesia, limited data directly compare their efficacy in managing pain following umbilical herniorrhaphy (8).

This study aims to evaluate and compare the analgesic effects of ultrasound-guided TAP block and RS block in patients undergoing elective umbilical hernia repair, focusing on postoperative pain scores, total analgesic requirement, and time to first rescue analgesia.

MATERIALS AND METHODS

This prospective, randomized, single-center clinical study was conducted in the Department of Anesthesiology and General Surgery at a tertiary care hospital over a period of six months, 60 adult patients aged between 18 and 65 years, classified as American Society of Anesthesiologists (ASA) physical status I or II, scheduled for elective umbilical hernia repair under general anesthesia were recruited.

Patients were randomly divided into two equal groups (n=30 each) using a computer-generated randomization table:

  • Group A: Received ultrasound-guided Transversus Abdominis Plane (TAP) block
  • Group B: Received ultrasound-guided Rectus Sheath (RS) block

 

Inclusion Criteria

  • Adults aged 18–65 years
  • ASA grade I or II
  • Scheduled for elective umbilical hernia repair with a midline incision
  • Provided informed consent

 

Exclusion Criteria

  • Known allergy to local anesthetics
  • Coagulation disorders or on anticoagulant therapy
  • Local infection at injection site
  • Chronic opioid use or chronic pain disorders
  • Obesity (BMI >35 kg/m²)

 

Anesthetic Procedure

All patients were premedicated with midazolam 0.03 mg/kg IV and fentanyl 2 µg/kg IV. General anesthesia was induced with propofol 2 mg/kg and vecuronium 0.1 mg/kg IV to facilitate endotracheal intubation. Anesthesia was maintained with a mixture of oxygen, air, and sevoflurane.

Following induction and prior to surgical incision, patients in Group A received an ultrasound-guided bilateral TAP block using a high-frequency linear probe. A 22G needle was advanced in-plane, and 20 mL of 0.25% bupivacaine was deposited between the internal oblique and transversus abdominis muscle layers on each side.

Patients in Group B underwent an ultrasound-guided bilateral RS block, with 20 mL of 0.25% bupivacaine injected into the posterior rectus sheath under ultrasound guidance on each side.

 

Postoperative Pain Assessment

Pain intensity was evaluated using the Visual Analog Scale (VAS) at 1, 4, 8, 12, and 24 hours after surgery. A VAS score >4 was considered significant, prompting administration of rescue analgesia (intravenous tramadol 50 mg).

 

The primary outcomes were:

  • VAS scores at predetermined intervals
  • Time to first request for rescue analgesia

 

Secondary outcomes included:

  • Total tramadol consumption in the first 24 hours
  • Occurrence of any adverse effects (nausea, vomiting, allergic reactions)

 

Statistical Analysis

Data were compiled and analyzed using SPSS version 22.0. Continuous variables were presented as mean ± standard deviation and compared using the independent t-test. Categorical variables were compared using the chi-square test or Fisher’s exact test. A p-value <0.05 was considered statistically significant.

RESULTS

A total of 60 patients were included in the study, with 30 patients in each group. Both groups were comparable in terms of age, gender distribution, body mass index (BMI), and ASA physical status (Table 1). There were no statistically significant differences in baseline demographic parameters between the two groups (p>0.05).

 

Pain Assessment (VAS Scores)

Visual Analog Scale (VAS) scores were significantly lower in Group A (TAP block) compared to Group B (RS block) at 4 and 8 hours postoperatively (p<0.05), while scores at 1, 12, and 24 hours did not differ significantly (Table 2). The lowest pain scores were observed at 8 hours in the TAP group (2.7 ± 0.6).

 

Analgesic Requirement and Time to First Rescue Dose

Patients in Group A had a longer duration before requiring the first dose of rescue analgesia (7.9 ± 1.3 hours) compared to Group B (5.5 ± 1.5 hours), which was statistically significant (p=0.003). Total tramadol consumption in the first 24 hours was also lower in the TAP group (112 ± 18 mg) than in the RS group (145 ± 22 mg) (p<0.01) (Table 3).

No major complications or adverse drug reactions were reported in either group.

 

Table 1. Baseline Demographic and Clinical Characteristics

Parameter

Group A (TAP)

Group B (RS)

p-value

Age (years)

44.5 ± 10.2

45.3 ± 9.8

0.72

Male:Female Ratio

18:12

17:13

0.79

BMI (kg/m²)

26.1 ± 2.5

26.5 ± 2.3

0.54

ASA Grade I/II

20/10

21/9

0.78

 

Table 2. Postoperative VAS Scores (Mean ± SD)

Time (hours)

Group A (TAP)

Group B (RS)

p-value

1 hour

3.8 ± 0.7

4.0 ± 0.8

0.29

4 hours

3.2 ± 0.6

4.6 ± 1.0

0.001

8 hours

2.7 ± 0.6

3.9 ± 0.9

0.002

12 hours

2.4 ± 0.5

2.7 ± 0.6

0.08

24 hours

1.8 ± 0.4

2.0 ± 0.5

0.12

 

Table 3. Analgesic Use and Rescue Time Comparison

Parameter

Group A (TAP)

Group B (RS)

p-value

Time to first rescue analgesia (hrs)

7.9 ± 1.3

5.5 ± 1.5

0.003

Total tramadol used (mg/24 hrs)

112 ± 18

145 ± 22

<0.001

DISCUSSION

Effective management of postoperative pain following abdominal surgeries remains a significant component of enhanced recovery protocols. This study compared the analgesic efficacy of two regional techniques—Transversus Abdominis Plane (TAP) block and Rectus Sheath (RS) block—in patients undergoing umbilical hernia repair. Our findings demonstrate that TAP block provides superior pain control in the early postoperative period, reduces opioid consumption, and prolongs the time to first rescue analgesia compared to the RS block.

The TAP block’s effectiveness in reducing somatic pain has been documented in various abdominal procedures, including cesarean section, appendectomy, and hernia repair (1,2). It targets the thoracolumbar nerves (T6-L1) that supply the anterior and lateral abdominal walls, thereby providing extensive analgesia (3). In contrast, the RS block primarily anesthetizes the terminal branches of lower intercostal nerves confined to the midline, thus offering more localized relief (4,5).

 

In our study, patients who received TAP block reported significantly lower VAS scores at 4 and 8 hours postoperatively, consistent with the findings of McDonnell et al., who noted enhanced analgesia with TAP block in abdominal surgeries (6). Moreover, the reduced total tramadol requirement and prolonged analgesia duration in the TAP group aligns with the observations of Niraj et al. and Petersen et al., who highlighted the opioid-sparing benefits of this approach (7,8).

 

Although the RS block is simpler to perform and effective in midline procedures, its limited dermatomal coverage may explain the higher pain scores observed in our study (9). The work of Hebbard et al. supports this limitation, emphasizing that RS block does not cover the lateral abdominal wall, which may still contribute to postoperative discomfort (10).

 

The importance of regional blocks in the context of multimodal analgesia cannot be overstated. Both blocks, when integrated with systemic analgesics, can enhance pain control while minimizing opioid-related adverse effects (11). Notably, no complications such as hematoma, local anesthetic toxicity, or infection were reported in our study, underscoring the safety of ultrasound-guided administration (12).

 

Our results also support the growing consensus that TAP block is a valuable adjunct for surgeries involving lower and central abdominal incisions, especially when early mobilization is a priority (13). However, it is essential to consider anatomical variations, technical proficiency, and ultrasound availability while selecting the block technique (14).

This study has limitations. It was a single-center trial with a relatively small sample size. Additionally, long-term outcomes such as chronic pain or functional recovery were not evaluated. Further multicenter studies with larger cohorts are needed to validate these findings and determine cost-effectiveness (15).

CONCLUSION

In conclusion, TAP block provides more effective postoperative analgesia than RS block in umbilical hernia repair, suggesting its preferred use in routine practice where feasible.

REFERENCES
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