Comment on “Evaluation of the efficacy of M-TAPA and EXORA block application for analgesia after laparoscopic cholecystectomy: a prospective, single-blind, observational study”

Dear Editor,

We read with interest the recent article by Ökmen et al. [1], which compared the analgesic efficacy of the modified thoracoabdominal nerve block via the perichondrial approach (M-TAPA) with that of the external oblique and rectus abdominis plane (EXORA) block in patients undergoing laparoscopic cholecystectomy. The authors demonstrated that both techniques yielded satisfactory postoperative analgesia in the T7–T11 dermatomes. However, they also acknowledged certain anatomical limitations, particularly in terms of achieving adequate coverage of the upper thoracic dermatomes (T5–T6) and medial anterior abdominal wall.

As discussed in their paper, thoracoabdominal innervation and fascial anatomy can hamper the consistent spread of local anesthetics in plane blocks [1,2]. In this context, we observed that the anatomical target of the EXORA block, as described by Ökmen et al., closely resembled that of the recto-intercostal fascial plane block (RIFPB), which had been defined in detail in a cadaveric study by Tulgar et al. in 2023 [3]. Both block techniques entail the administration of local anesthetic between the 6th and 7th costal cartilages and the posterior aspect of the rectus abdominis muscle, aiming to access a comparable interfascial plane.

In view of the above, we performed a bilateral RIFPB in a high–risk patient scheduled for wound-revision surgery involving the upper abdominal wall. The patient was a 75-year-old male with a history of atrial fibrillation, moderate mitral regurgitation, severe tricuspid insufficiency, chronic kidney disease, and pulmonary hypertension. His pulmonary artery pressure was 60 mmHg. The patient was classified as American Society of Anesthesiologists (ASA) III. Given the elevated risk associated with general anesthesia in this patient, we opted for a purely regional anesthetic technique, and selected ultrasound-guided bilateral RIFPB.

The patient was monitored using a standard ASA protocol, including noninvasive blood-pressure measurement, three-lead electrocardiography, and pulse oximetry. Oxygen supplementation (5 L/min) was initiated. Sedation was induced using midazolam (1 mg) and ketamine (20 mg). With the patient in a supine position, a high-frequency linear ultrasound probe was placed approximately 2–3 cm lateral to the xiphoid process. Using an in-plane approach, the needle was advanced from cephalad to caudad into the interfascial plane between the 6th and 7th costal cartilages and the rectus abdominis muscle. Hydrodissection with saline was performed to confirm the correct needle placement, after which 30 ml of 0.25% bupivacaine was administered bilaterally.

After confirming that the sensory block extended from T5 to T10, the surgical procedure was initiated under mild sedation. The procedure lasted 65 min and was completed without complications (Fig. 1). The patient remained hemodynamically stable throughout the procedure, without the need for additional systemic anesthetics. During intraoperative manipulation of the omentum, the patient reported mild discomfort, which was promptly managed with 20 mg ketamine and 50 µg fentanyl. Postoperative pain was first noted at the 4th hour and was effectively controlled using standard non-opioid analgesics.

Fig. 1.

(A) Preoperative view of the upper abdominal wound before revision. (B) Intraoperative view showing the superficial nature of the surgical procedure. (C) Immediate postoperative image with linear closure and ruler for scale. (D) Final postoperative view under bilateral recto-intercostal fascial plane block without general anesthesia.

This case illustrated the potential utility of the RIFPB, particularly in high-risk surgical candidates and in cases where extended dermatomal coverage is required. We are grateful to Ökmen et al. [1] for drawing attention to the anatomical boundaries of conventional approaches and to Tulgar et al. [3] for contributing a novel perspective that may enhance the clinical versatility of fascial plane blocks.

Written informed consent was obtained from the patient for publication of this case report and accompanying images.