Clinical Scorecard: Combining Intraoperative Autonomic Nerve Block with Transversus Abdominis Plane Block for Left-Sided Colectomy

At a Glance

Key Highlights

• Visceral pain after left-sided colectomy is poorly managed by classical analgesic strategies and contributes to postoperative nausea and vomiting (PONV) and prolonged hospital stay.
• The technique involves laparoscopic-guided TAP blocks bilaterally and targeted infiltration of autonomic plexuses (superior hypogastric and inferior mesenteric) with a local anesthetic mixture.
• This combined block approach aims to reduce visceral pain and improve postoperative recovery; further randomized studies are planned to validate efficacy.

Guideline-Based Recommendations

Diagnosis

• Identify patients undergoing minimally invasive left-sided colonic resections who may benefit from enhanced visceral pain control.

Management

• Perform bilateral laparoscopic-guided TAP blocks at three points lateral to recti muscles with 10 cc of anesthetic mixture per point.
• Expose inferior mesenteric and superior hypogastric plexuses intraoperatively via medial-to-lateral approach.
• Infiltrate 7–8 cc of local anesthetic mixture around each plexus in 1 cc increments with aspiration before injection to avoid intravascular administration.
• Infiltrate trocar sites at skin and parietal peritoneum with 1–2 cc of anesthetic mixture.

Monitoring & Follow-up

• Confirm correct plane infiltration during TAP block by visualizing fluid dissemination above the transversus abdominis muscle.
• Observe tissue expansion around plexuses as confirmation of adequate infiltration.
• Monitor for signs of local anesthetic systemic toxicity and ensure aspiration prior to injection.

Risks

• Potential for inadvertent intravascular injection; aspiration before injection is critical.
• Anatomical differences between stomach and left colon require precise localization to avoid ineffective block or complications.
• Further studies needed to establish safety and reproducibility.

Patient & Prescribing Data

Patients undergoing minimally invasive left-sided colectomy

Use of a combined local anesthetic mixture (20 cc liposomal bupivacaine 266 mg, 30 cc Marcaine 0.5% HCl, and 50 cc normal saline) totaling 100 cc for intraoperative autonomic nerve and TAP blocks may mitigate visceral pain and reduce PONV.

Clinical Best Practices

• Prepare anesthetic mixture in advance ensuring correct concentrations and volumes.
• Use laparoscopic guidance to accurately identify TAP block injection sites and autonomic plexuses.
• Perform TAP blocks bilaterally at three levels lateral to recti muscles before trocar insertion.
• Use medial-to-lateral approach for exposure of inferior mesenteric and superior hypogastric plexuses.
• Inject local anesthetic incrementally with aspiration to prevent intravascular injection.
• Infiltrate trocar sites to reduce parietal pain.
• Plan for further clinical trials to validate technique efficacy and safety.

References

• Daes et al. - Autonomic neural blocks in laparoscopic sleeve gastrectomy
• Postoperative nausea and vomiting linked to visceral pain
• Technique description and clinical rationale