Multilevel retro-superior costotransverse ligament block with liposomal bupivacaine for open hepatectomy: a case report

Postoperative analgesia after open liver resection is challenging owing to both somatic and visceral pain. Retro-superior costotransverse ligament block is a novel ultrasound-guided paraspinal block that may provide a safer and effective alternative to thoracic epidural analgesia, thoracic paravertebral block, and erector spinae plane block, particularly in patients with coagulation concerns.

A 38-year-old Han Chinese woman underwent open liver resection under general anesthesia. Preoperatively, ultrasound-guided retro-superior costotransverse ligament block was performed at the T6-7, T8-9, and T10-11 levels, with 10 mL of a bupivacaine mixture injected per level (total 30 mL: 20 mL of liposomal bupivacaine and 10 mL of plain bupivacaine).The patient achieved sensory blockade from T4 to T12 in the anterior and lateral thoracic wall, and from T3 to L1 posteriorly. Intraoperative hemodynamics remained stable. Postoperatively, visual analog scale scores for both resting and coughing remained between 0 and 2 for 48 h. No rescue analgesics were required, and the patient-controlled analgesia pump was not activated.

Retro-superior costotransverse ligament block with liposomal bupivacaine may provide effective, long-lasting, and opioid-sparing analgesia after major abdominal surgery, and is a promising option.