Background:
High level evidence now supports the use of multimodal, opioid-sparing analgesia to improve postoperative recovery after upper GI surgery.
The subcostal transversus abdominis plane block (SCTAP) is a well described method of regional anaesthesia for the abdominal wall, targeting nerves derived from the anterior rami of thoracolumbar spinal nerves (T6 to L1).
Both the anatomical approach and the volume administered can affect the quality of the block. Conventional descriptions recommend 20-30mL of injectate bilaterally, however in canine cadavers, higher weight based volume is associated with improved spread. Adjuncts such as dexamethasone and alpha 2 agonists may extend the duration of analgesic benefit, but no agent is convincingly superior.
Proposal:
We hereby describe the “Big Shot Block” with applicability to all major upper GI laparoscopic operations. A total of 200mL of 0.1% ropivacaine and 75 micrograms of clonidine substantiates bilateral injections of 100 mL each, administered by the surgeon parallel to the subcostal margin and anterior to the mid axillary line. A sausage shaped convexity should be observed as the local anaesthetic is delivered between the transversus abdominis and internal oblique muscles.
The proposal seeks to validate the efficacy and safety of this elegant single shot technique performed efficiently under direct laparoscopic vision soon after the pneumoperitoneum has been established, in the context of an opiate sparing general anaesthetic.
Our experience is that patients receiving this combination demonstrate a high level of satisfaction, objectively consume less opioid, mobilise earlier and discharge home sooner with less nausea and no adverse effects.