Background and aims Enhanced recovery after surgery (ERAS) protocols should incorporate multimodal analgesic usage with regional anesthesia techniques to improve pain control. We present a case of incisional hernia repair using a combination of rectus sheet block and subcostal transvers abdomininis plane (TAP) block for surgical anesthesia.

Methods The patient was 78-year-old male who was undergoing planned incisional hernia repair. His medical history included hypertension, diabetes mellitus, coronary artery disease and chronic obstructive pulmonary disease. Performing general anesthesia was at high risk. We planned to perform abdominal wall anesthesia by implementing a combination of rectus sheet block and subcostal transvers abdominis plane block under ultrasound guidance. Preoperative sedatives were minimized to 50 µg fentanyl and 1 mg midazolam. We administered 0.5% bupivacaine 10 ml for the right and 10 ml for left subcostal TAP blocks, 5 ml for right and 5 ml for left rectus sheet blocks at T9 dermatomal level.

Results The surgery lasted 35 minutes. A 10 cm incision was performed starting from 2 cm distal, up to 8 cm from the umbilicus (figure 1). The patient did not need any additional sedation or analgesics during the surgery. No complications were observed during the block procedure and the surgery. The abdominal wall anesthesia provided 16 hours of postoperative analgesia and acetaminophen intravenous was continued thereafter.

Conclusions Our case demonstrated that lesion targeted, ultrasonography guided abdominal wall anesthesia provided sufficient surgical anesthesia and postoperative analgesia in incisional hernia repair surgery with possibility of early discharge and opioid-free postoperative analgesia.