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255]

284 Original article

Ultrasound-guided transversus abdominis plane block versus

caudal block for postoperative analgesia in children undergoing
unilateral open inguinal herniotomy: a comparative study
Ashraf A. Ahmeda, Ayman A. Rayanb
1
Department of Anesthesia, Ain Shams
University, 2Department of Anesthesia,
Menoufia University, Menoufia, Egypt
Correspondence to Ashraf A. Ahmed, MD,
Prince Sultan Armed Forces Hospital, Madinah
15616, Kingdom of Saudi Arabia
Tel: 00201111266590;
E-mail: kader2a@hotmail.com  Forty ASA I–II, 1–5-year-old children scheduled for elective unilateral open inguinal herniotomy
Received 20 August 2014
Accepted 17 November 2014
Ain-Shams Journal of Anesthesiology
2016, 9:284–289
Background
Ultrasound (US)-guided transversus abdominis plane (TAP) block is an effective technique in
providing analgesia for abdominal surgery. This study was designed to evaluate the efficacy
of a US-guided TAP block and to compare it with a caudal block in unilateral day-case open
inguinal hernia repair in children.
Patients and Methods
were studied. All patients received general anesthesia; sevoflurane was used for induction and
maintenance of anesthesia and laryngeal mask airway (LMA) was used to secure the airway.
After securing an intravenous cannula, patients were randomized to a US-guided TAP block
(n = 20) (group T) using 0.5 ml/kg 0.25% bupivacaine, injected on the same side of surgery,
and group C received a caudal block using 1 ml/kg 0.2% bupivacaine (n = 20). Surgery was
allowed 15 min after administration the block. Block failure was considered in case of gross
movement or more than 20% change in heart rate and/or ABP persisting more than 1 min
after skin incision. Any adverse events were recorded. After surgery, patients remained for
4 h in the recovery room. Postoperative analgesia was evaluated using Children and Infants
Postoperative Pain Scale (CHIPPS). An anesthesiologist, who was not part of the study team,
evaluated the need for rescue analgesia in the intraoperative and postoperative period and a
recovery nurse collected the data. If the CHIPPS score was greater than 4, a rescue analgesia
of 20 mg/kg acetaminophen was administered.
Results
No difference was found in hemodynamics in both groups. Also, intraoperative fentanyl
consumption was not different and no rescue analgesia was required in the postanesthesia
care unit.
Conclusion
A US-guided TAP block is as effective as a caudal block in providing immediate postoperative
analgesia in inguinal hernia repair.

Keywords:
caudal block, inguinal herniotomy, ultrasound-guided transversus abdominal plane block

Ain-Shams J Anesthesiol 9:284–289

© 2016 Department of Anesthesiology, Intensive Care and Pain Managment,
Faculty of Medicine, Ain-Shams University, Cairo, Egypt
1687-7934

a landmark technique through the lumbar triangle or

Introduction
Caudal epidural analgesia is the most common regional
technique performed in children. It has been used for
many years as a sole anesthetic, adjuvant to a general
anesthesia, and to provide postoperative analgesia for
subumbilical procedures; it is the preferred technique
in groin surgery [1].
The caudal approach to the epidural space is preferred
in children because of the ease of access through the
sacrococcygeal ligament and the potential decreased
risk of injury to neural structures at this level compared
with access at the lumbar and thoracic levels [2].
The transversus abdominis plane (TAP) block is a new
regional anesthesia technique that provides analgesia
after abdominal surgery [3]. It can be performed using
© 2016 Ain-Shams Journal of Anaesthesiology | Published by Wolters Kluwer - Medknow
with ultrasound (US) guidance.
As safe and effective regional anesthesia requires
local anesthetics to be placed in close proximity
to target nerves without injury to target nerves
or adjacent structures, the use of US in regional
anesthesia in children was shown to improve
sensory and motor block, and might reduce the risk
of complications [4].
Few studies have described the use of a TAP block for
hernia repair in children [5–7]; however, it has not been
compared with the most commonly used technique,
caudal block, as yet.
The aim of this study was to evaluate the analgesic
efficacy of a US-guided TAP block and to compare it
DOI: 10.4103/1687-7934.182270
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with a caudal block in children undergoing day-surgery
unilateral opening unilateral herniotomy.
Patients and Methods
After obtaining approval of the Hospital Research
and Ethics Committee (King Abdul-Aziz air base
hospital], Dhahran, KSA, 40 ASA I–II patients aged
1–5 years scheduled for elective outpatient unilateral
open inguinal herniotomy were enrolled. A written
informed consent was obtained from the father or the
legal guardian of the patient.
Patients were excluded if there was parental refusal,
any contraindication to a caudal block, for example,
bleeding disorders, local site infection, and a history of
relevant drug allergy.
All patients received general anesthesia; sevoflurane was
used for the induction and maintenance of anesthesia
(together with NO2 60% in O2) and LMA was used to
secure the airway. Standard monitoring (ECG, ABP,
SPO2, and end-tidal CO2) was applied to all patients
and the monitoring results were recorded every 5 min.
After securing an intravenous cannula, patients were
randomized, by computer-generated random tables
and the sealed-envelope technique, to receive either
a US-guided TAP block (group T) or a caudal block
(group C).
In group T, patients were placed in a supine position and
a high-frequency 6–13 MHz, hockey-stick transducer,
connected to a SonoSite M-Turbo portable US
machine (SonoSite, Bothell, Washington, USA), was
used. The probe was initially positioned perpendicular
to the anterior abdominal wall to visualize the rectus
abdominis muscle at the level of the umbilicus. The
ultrasound probe was moved laterally at the same level
to scan the anterolateral part of the abdominal wall
to obtain a transverse view of the abdominal layers:
external oblique abdominal muscle, internal oblique
abdominal muscle, transversus abdominis muscle,
and most deeply, peritoneal cavity, from superficial
downward (Fig. 1).
After skin disinfection, a 22-G 50-mm needle with an
injection line (Stimuplex A; B/Braun Melsungen AG,
Berlin, Germany) was used. Once the tip of the needle
was placed in the space between the internal oblique
abdominal muscle and transversus abdominis muscle in
the same operative site, using an ‘in-plane’ technique to
visualize the entire needle, and after negative aspiration,
bupivacaine 0.5 ml/kg 0.25% was injected. An injection
was considered successful when an echolucent lens
shape appeared between the two muscles.
TAP vs. caudal block Ahmed and Rayan 285
In group C, patients were placed in the left lateral
position and a caudal block was administered under
aseptic conditions using 1 ml/kg 0.2% bupivacaine.
The maximum dose of 2 mg/kg bupivacaine was not
exceeded in both groups.
Both TAP and caudal techniques were performed
by the same anesthetist (first author) who was not
involved in patient management after performing the
block. Patients were managed by another anesthetist
who was unaware of the technique used.
Successful blockade was defined by the absence of
gross movement or a significant (>20%) change in
heart rate (HR) and/or ABP on application of skin
incision, which was allowed 15 min after performing
the technique. Signs of inadequate analgesia (gross
movement or >20% change in HR and/or ABP)
persisting more than 1 min after skin incision were
managed by increasing the sevoflurane concentration
and fentanyl 1 μg/kg and the block was considered a
failure (those patients were administered paracetamol
20 mg/kg per rectum immediately after the completion
of surgery). Fentanyl was repeated as clinically indicated
and the total number of intraoperative fentanyl doses
administered was recorded.
After surgery, patients were observed for 4 h in the
postanesthesia recovery unit by recovery room nurses
who were blinded to the technique used. Postoperative
analgesia was evaluated using the Children and Infants
Postoperative Pain Scale (CHIPPS) [8]. CHIPPS
is a well-validated and reliable scale in determining
postoperative analgesia demand in children (Table 1).
It consists of five items (crying, facial expression,
posture of the trunk, posture of the legs, and motor
restless) with a score of 0–2 for each item. Values
Figure 1
Transverse ultrasound view of the external oblique abdominal muscle,
internal oblique abdominal muscle, and transversus abdominis
muscle.
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286 Ain-Shams Journal of Anesthesiology
Table 1 Children and Infants Postoperative Pain Scale [9]
Item Structure
Crying None
Moaning
Screaming
Facial expression Relaxed/smiling
Wry mouth
Grimace (mouth and eyes)
Posture of the trunk Neutral
Variable
Rear up
Posture of the legs Neutral, released
Kicking about
Tightened legs
Motor restlessness None
Moderate
Restless
between 0 and 3 indicate a pain-free state and 4 points
or more identify the increasing need for supplemental
analgesia. Motor weakness was determined using a
simple three-point scale (0, no movements; 1, possible
to move the legs; and 2, able to stand) [9].
CHIPPS and motor weakness were measured every 30
min for 4 h. If the CHIPPS score was greater than 4,
rescue analgesia of 20 mg/kg rectal acetaminophen was
administered.
The duration of analgesia, defined as the time from
termination of anesthesia to the first analgesic
administration, was also recorded. If no rectal
acetaminophen was necessary within 4 h, the duration
of analgesia was counted as 4 h. The sites of injection
of the TAP block and the caudal area were inspected to
detect complications such as hematomas. Any adverse
events were also recorded.
Patients were discharged home 4 h postoperatively
according to the study protocol. Full instructions were
provided together with the postoperative medications.
Home analgesia was administered in the form of a
suppository of paracetamol 15 mg/kg 4–6 h; the total
dose should not exceed 60 mg/kg in 24 h.
The primary outcome was the proportion of patients
who required rescue analgesia in the recovery room.
The secondary outcomes included pain score in the
recovery room, time to rescue analgesia, and number of
unplanned admissions.
Sample size and statistical methods
Group sample sizes of 18 per group will achieve an
80% power to detect a difference between the group
proportions of 0.08. The proportion in the TAP group
is assumed to be 0.9000 under the null hypothesis
and 0.9800 under the alternative hypothesis. The
Points proportion in caudal blocks is 0.9000. The statistical
0 test used was the two-sided Z-test with pooled
1 variance. The significance level of the test was set at
2
0.05. Twenty patients per group were included to
0
replace any dropouts. The collected data were coded,
1
2
tabulated, and statistically analyzed using the SPSS
0 program (Statistical Package for Social Sciences)
1 software version 17.0 (SPSS Inc., Chicago, Illinois,
2 USA).
0
1 Data were expressed as mean values ± SD for numerical
2 parametric data, median (range) for nonparametric
0 data, and n (%) for categorical data. An independent
1
t-test was used in cases of two independent groups with
2
parametric data and a paired t-test was used in cases
of two dependent groups with parametric data. The
Mann – Whitney U-test was used for nonparametric
data and the χ2-test for discrete (categorical) variables,
with P values less than 0.05 considered statistically
significant.
Results
Forty patients who underwent elective outpatient
unilateral open inguinal herniotomy were included
in this study. Abdominal muscles, the needle, and the
spread of the local anesthetic could be observed clearly
in all patients in group T and the caudal block was
performed successfully in all patients in group C.
No case of blood aspiration was recorded during the
technique in group T. However, one patient in group
C received blood aspiration and the trial was repeated
twice until the caudal injection was administered
satisfactorily. No other local or systemic complications
related to the technique of regional anesthesia or
surgeries were reported.
The groups did not differ with respect to age, weight,
sex, duration of surgery, and duration of anesthesia
(Table 2).
One patient in group T showed signs of block failure
(HR and/or ABP >20% of the baseline for more than
1 min) and was excluded from the study. The block was
considered successful for the rest of the patients and
no intraoperative fentanyl was used. Table 3 shows the
hemodynamic variables in both groups.
No rescue analgesia was required in the postanesthesia
recovery unit for both groups. The CHIPPS score
showed a tendency to be higher in group T compared
with group C; however, the difference was not
statistically significant (Table 4).
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TAP vs. caudal block Ahmed and Rayan 287

Table 2 Demographic and operative data in both groups and still most commonly used technique in children.
Variable Group T Group C P value It is recommended mainly for surgical procedures
Age (months) 23.6 ± 9.96 25.5 ± 7.8 0.62 below the umbilicus, including inguinal hernia repair,
Sex urinary, and digestive tract surgeries, and orthopedic
M 10 11 0.75 procedures on the lower extremities [10].
F 10 9
Weight (kg) 14 ± 4.2 14.5 ± 2.5 0.59
The TAP block is an anatomical compartment block.
Duration of surgery (min) 21.25 ± 3 20.1 ± 2.5 0.2
The nerve endings originate from T7 to L1 and,
Duration of anesthesia (min) 34.3 ± 1.6 33.4 ± 2.03 0.114
including the ilioinguinal and iliohypogastric nerves,
Data were expressed as mean ± SD or number; P > 0.05 was
considered statistically nonsignificant. are the target nerves. TAP block can be performed
blindly on the basis of the click perceived when the
needle passes through the fascia of the external and
Table 3 Heart rate and mean arterial pressure in both groups
internal oblique and again between the internal oblique
Parameter Group T Group C P value
and transversus abdominis muscles; however, the use
Heart rate before 116.4 ± 2 114 ± 2.3 0.3b
of US guidance is likely to improve the reliability of
Heart rate after 112.7 ± 2 103.2 ± 2.2 0.9b
0.3a 0.22a
the block [11]. US allows the precisely visualization
MAP before 92.6 ± 6 92.3 ± 5 0.15b
of the blocking needle (the entire needle or its tip
MAP after 90 ± 5.5 90.5 ± 4 0.44b depending on the use of the inplane or the out-of-
0.06a 0.54a plane technique), the anatomy (the three abdominal
Data were expressed as mean ± SD; MAP, mean arterial pressure; muscle layers, the peritoneum, and intraperitoneal
a
Comparison between before and after skin incision; bComparison visceral structures), and also the real-time assessment
between the two groups; P > 0.05 was considered statistically
nonsignificant.
of the local anesthetic distribution characterized by an
anechoic image between the internal oblique and the
transversus abdominis muscles [12].
Table 4 Children and Infants Postoperative Pain Scale score
in the first 4 h postoperatively
Although the preliminary literature in infants and
Post operative period Group T Group C P value
children suggests that the TAP block provides effective
½h 1 (0–1) 0.5 (0–1) 0.75
analgesia following various umbilical and lower
1h 1 (0–1) 0.5 (0–1) 0.34
abdominal procedures, including laparoscopy [13], few
1½ h 1 (0–2) 1 (0–2) 0.98
2h 1 (0–2) 1 (0–2) 0.06
studies have been carried out showing its analgesia
2½ h 1 (0–2) 1 (0–2) 0.06 efficacy in hernia repair surgery [5–7], and none has
3h 1 (1–2) 1 (1–2) 0.5 compared it with the most commonly used regional
3½ h 1 (0–2) 1.5 (1–2) 0.76 technique in children: the caudal block.
4h 2 (1–3) 2 (0–3) 0.33
Data were expressed as median and range; P > 0.05 was The results of this study show that a US-guided TAP
considered statistically nonsignificant. block is as effective as a caudal block in providing
intraoperative and postoperative analgesia for unilateral
No signs of motor blockade could be observed after the day-surgery hernia repair in children. Both techniques
first postoperative hour in any of the patients. During (TAP block and caudal block) were successful in
the first postoperative hour, one patient in group C providing effective intraoperative and postoperative
had a motor blockade score of 1, whereas none of the analgesia for the study patients (except for one patient
patients in group T had any sign of motor blockade. in group T). No intraoperative fentanyl was used and
no postoperative rescue analgesia was required during
All patients were discharged home 4 h postoperatively the study period (4 h postoperatively).
according to the study protocol and nonrequirement of
hospital admission. In agreement with our results, TAP block provided
effective analgesia in a prospective study of eight children
No adverse events were noted during the observation undergoing unilateral inguinal hernia repair  [5]. All
period in the postanesthesia recovery unit. patients recorded postoperative pain scores of 0–2
and seven patients required no postoperative opiates;
one patient received intravenous morphine for the
treatment of emergence agitation. Three patients
Discussion showed signs of intraoperative incomplete analgesia
Regional anesthesia attenuates the stress response to and were treated with fentanyl (<0.5 μg/kg). The short
surgery and produces excellent postoperative analgesia time between the block and the skin incision, 5 min,
in infants and children. Caudal anesthesia is the oldest may explain the incomplete intraoperative analgesia. In
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288 Ain-Shams Journal of Anesthesiology
our study, skin incision was allowed 15 min after the
block.
In a prospective randomized comparative study, Sahin
et al. [7] evaluated the analgesic efficacy of a TAP
block (US-guided) using 0.5 ml/kg levobupivacaine
0.25% in comparison with wound infiltration with
0.2 ml/kg levobupivacaine 0.25% during the first 24 h
after surgery in 57 children (2–8 years) undergoing
inguinal hernia repair. The mean time to first analgesic
was significantly longer in the TAP group than in the
infiltration group (17 ± 6.8 vs. 4.7 ± 1.6 h, respectively;
P < 0.001) and 45% of the patients in the TAP group
did not require any analgesic within the first 24 h.
However, Fredrickson et al. [6] under US guidance,
compared TAP blocks with ilioinguinal blocks in
children undergoing elective inguinal surgery. No
difference was found in the intraoperative fentanyl
requirements; however, more children in the TAP group
reported pain in the recovery unit and required more
analgesia in comparison with the ilioinguinal group.
The discrepancy in the results of the TAP group with
ours can be explained partially by the type of surgery;
only hernia repair was explored in our study versus
groin surgery (inguinal herniotomy, hydrocelectomy,
orchidopexy) in the Fredrickson study [6].
Also, Stewart et al. [14] in an interesting study, found
that after inguinal hernia repair, children experience
mild pain that can be treated with paracetamol and
only a few required analgesia 24 h postoperatively,
whereas orchidopexy was associated with greater and
more prolonged pain requiring a multimodal analgesia
approach (paracetamol and ibuprofen) for a longer time.
The authors (Fredrickson and colleagues) acknowledged
the limitations of their study, which include the possible
observer bias in the data collected by the principal
investigator/operator, who was not blinded to the
treatment group, and midazolam premedication was
not controlled, which may have confounded recovery
room and day-stay pain assessment [6].
Variable doses were used in US-guided TAP blocks in
neonates, infants, and children for different surgeries;
0.2, 0.3, 0.5, and 1 ml/kg were all tried [6,7,15,16].
We chose 0.5 ml/kg for use in this study as the TAP
block was unilateral and the total dose was limited to
2 mg/kg, which is less than the 3 mg/kg upper dose
limit suggested by Suresh and Chan [15] for a TAP
block in children.
Femoral nerve block (partial or complete) is a potential
complication of a TAP block that may not be avoided
completely even with US guidance. The transversalis
fascia includes the fascial plane deep to the rectus
abdominis muscles. This fascial plane is continuous with
the fascia iliaca. An injection of local anesthetic into
the TAP can potentially spread along the transversalis
fascia to the fascia iliaca, thereby blocking the femoral
nerve [17]. In this study, no signs of motor blockade
could be observed in group T, whereas one patient in
group C had a motor blockade score of 1 during the first
postoperative hour. However, this did not affect patients
discharge from hospital admission was required.
Although one patient had bloody aspiration in group
C, no patient had symptoms or signs of systemic local
anesthetic toxicity, and no other local or systemic
complications related to the technique of regional
anesthesia or surgeries were reported in both groups;
no adverse events were noted during the observation
period in the postanesthesia recovery unit.
We found a TAP block under US guidance in children
to be a safe and easy to perform technique with effective
intraoperative and postoperative analgesic effects
in unilateral day surgery hernia repair. However, as
different surgeries produce different levels of pain [14],
the results of this study cannot be generalized to other
groin or abdominal surgeries and further studies are
still required to show the comparative effectiveness
of TAP blocks among the various other analgesic
techniques in different abdominal surgeries.
The short postoperative pain assessment time, 4 h, is a
limitation in this study and should have been followed
by telephone calls; however, because of cultural reasons,
this could not be done.
Conclusion
A US-guided TAP block is as effective as a caudal block
in providing intraoperative and postoperative analgesia
in day-case open inguinal hernia repair in children.
Acknowledgements
Conflicts of interest
None declared.
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