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.
A 68-year-old female patient (161 cm, 50 kg) with a 21-mm large mass in the upper pole of the right kidney was scheduled for RAPN peritoneal approach. The anesthetic method and block were similar to those in case 1.\nThe operative and anesthetic times were 271 and 326 min, respectively. The patient intraoperatively received intravenous fentanyl 200 μg and acetaminophen 750 mg. The surgical procedure was different from that of case 1 with respect to the placement of a single and surgery time extension. Postoperative pain was managed in the ward using continuous intravenous infusion of 25 μg/h fentanyl combined with 25 μg fentanyl for IV-PCA with 10-min lockout.\nA pinprick test performed at 2 h after surgery revealed that the anesthetized dermatomal range was Th7–Th12. The NRS scores were 3-0-0-0/10 at rest and 5-1-1-3/10 on movement at 2, 12, 24, and 48 h after surgery, respectively. Acetaminophen was administered once at POD 0. IV-PCA was stopped at 67 post-surgery hours. The total fentanyl amount post-operatively used was 2425 μg. She was discharged without adverse events at 7 days after surgery.