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 64-year-old male (46 kg, 152 cm) presented with postthoracotomy pain syndrome 1 year after undergoing right bilobectomy. He had severe pain (9/10 on NRS) over the anterior and posterior right chest area and described it as burning, tingling, and current-like sensation around the thoracotomy scar at the T8-T9 level. Despite the high dosage of oral analgesics, he experienced significant pain. A right ESP block with 20 mL of 0.375% ropivacaine and 40 mg of triamcinolone was performed at the T8 level. Following the injection, pain was relieved in few minutes (0 on 10 on NRS) with sensory blockade from T5 to T12 on the right side. NRS score was noted for 24 h []. The patient was discharged with oral medications tapered. The patient remained pain-free for 1.5 months without consumption of any other oral analgesic. A second ESP block was performed with 20 mL of 0.25% ropivacaine and 40 mg triamcinolone which again produced significant analgesia lasting 2 weeks.