Background and Aims Anesthesia for open cholecystectomy are traditionally either under general or neuraxial anesthesia. Fascial plane blocks are often reserved for postoperative analgesia only.¹ We report a case of an ASA Class IV patient with obstructive jaundice in severe cholangitis who underwent open cholecystectomy and T-tube drain under rectus sheath and subcostal TAP blocks.

Methods A 58-yo male patient was received in the operating room for tube cholecystostomy. He was noted to be hypotensive, hypernatremic, and drowsy. A linear transducer was placed transversely next to the umbilicus on the right where 12 ml of 0.2% ropivacaine was deposited.² Twenty-five (25) mls of 0.2% ropivacaine was deposited into the right subcostal area for the TAP block.² LA infiltration in the incision site was also done. The intraoperative cholangiogram was unremarkable however the gallbladder was emphysematous and macerated. The surgeons decided to proceed with open cholecystectomy with T-tube placement. Midazolam and fentanyl were used for sedation. Paracetamol 1g and tramadol 50mg IV were also given intraoperatively.

Results There was no complaint of pain nor wide swings in vital signs. Blood loss was at 650cc with intermittent episodes of tachycardia and hypotension which was responsive to norepinephrine. Surgery lasted 6 hours with the surgeon not noting any difficulty in retraction. The patient was fully awake thereafter.

Conclusions The use of fascial plane blocks as the sole technique in intraperitoneal anterior abdominal procedures was successful in this case. The technique may prove useful in patients who are hemodynamically unstable and have poor ASA classification scores.³