A 71-year-old male patient (174 cm, 56 kg) with a 15-mm large mass in the upper pole of the left kidney was scheduled for the RAPN peritoneal approach. Rapid induction was achieved using fentanyl, propofol, and rocuronium, which were added after establishing peripheral intravenous access. Anesthesia was maintained using desflurane and remifentanil. After tracheal intubation, and assuming the right decubitus position, the anterior QLB and ESPB were performed (Fig. ). A convex probe (2–5 Hz) was placed on the L2 vertebral body, and we attempted to obtain the shamrock view, which overlooks the quadratus lumborum muscle (QLM), erector spinae muscle (ESM), psoas major muscle (PMM), and vertebral body. A 100-mm block needle (20-G Tuohy needle) was inserted using the in-plane technique; moreover, 30 mL of 0.25% ropivacaine was applied between the QLM and PMM as the anterior QLB. Subsequently, the ESPB was performed at the transverse process of Th10. From this point, the needle was inserted in the caudal-to-cephalad direction. After confirming that the needle reached the ESM, we injected 30 mL of 0.25% ropivacaine. The operation was performed via the peritoneal approach with six port holes. The operative and anesthetic times were 209 and 294 min, respectively.\nThe patient intraoperatively received intravenous fentanyl 300 μg and acetaminophen 1000 mg. Postoperative pain was managed in the ward using continuous intravenous infusion of 15 μg/h fentanyl combined with 15 mcg fentanyl for intravenous patient-controlled analgesia (IV-PCA) with a 10-min lockout.\nA pinprick test was performed 2 h post-surgery using the Semmes-Weinstein monofilament 2.0 g (SAKAI Medical Co., Tokyo, Japan) as part of the postoperative procedures by someone who did not perform the blocks. The pinprick test revealed that the anesthetized dermatomal range was Th7–Th12. However, tactile sensation was normal around the port site in the midline of the umbilicus. The numerical rating scale (NRS) was 0-0-0-0/10 at rest and 1-1-1-5/10 on movement at 2, 12, 24, and 48 h after surgery, respectively. IV-PCA was stopped at 20 h after surgery due to postoperative nausea and low NRS value. The total fentanyl amount postoperatively used was 450 μg. Acetaminophen was administered once at postoperative day (POD) 1. He was discharged without any adverse events at POD 6.
Case 1: A 38-year-old male (weight 75 kg, ASA status III) was scheduled for right total hip arthroplasty (THA) due to severe bilateral rigid and sore hip joints. He had a history of ankylosing spondylitis for more than 18 years. Despite a long term usage of sulfasalazine and “painkiller”, the patient developed a rigid kyphotic and scoliotic deformity. An overall physical examination revealed rheumatoid arthritis involved most articles in the body resulting in limited movement and swelling of interphalangeal joints, metacarpophalangeal joints, elbow joints, shoulder joints, and ankle joints, with rigid bilateral hip and knee joints preventing any walk. The airway assessment revealed a Mallampati class III, interincisor distance of 3 cm, and rigid neck incapable of any movement. X-ray of his cervical, thoracic and lumbar vertebrae and pelvis revealed a loss of physiological curvature of the vertebral column, kyphosis, hyperplasia at the edge of the vertebrae, “bamboo” like bony bridge, blurred facet joints, and calcification of ligament, a fusion of both sacroiliac joints, rough articular face and narrowed articular cavity and hyperplasia of both hip joints (Fig. ). After administration, he received immunosuppressive therapy, with prednisone 20 mg per day, and methotrexate 10 mg once per week, and anti-TNF therapy with etanercept (TNF receptor fusion protein) 25 mg i.h. twice per week, and anticoagulation therapy with low-molecular-weight heparin 4000 U per day.