Which fascial plane block is right for my patient? A practical decision-making algorithm for abdominal surgery

Optimizing postoperative pain management is central to successful recovery following abdominal surgery and is a key component of enhanced recovery protocols. While multimodal analgesia is considered standard practice, selecting the most appropriate regional analgesic technique remains challenging, especially when neuraxial analgesia is contraindicated or undesirable. Ultrasound-guided abdominal fascial plane blocks have emerged as valuable alternatives, offering targeted somatic analgesia with favorable safety profiles. However, the growing number of available techniques has created uncertainty regarding optimal block selection for specific abdominal surgeries.

Our clinical decision tool aims to complement existing guidelines regarding fascial plane blocks with a simple algorithm to help the general anesthesiologist choose an appropriate fascial plane block for specific abdominal surgeries. We have also considered real-world factors such as ultrasound availability and institutional support for continuous catheters. Within this review, we discuss the current evidence and technical performance for the following procedures: transversus abdominis plane block, rectus sheath block, external oblique intercostal plane block, ilioinguinal and iliohypogastric nerve block, and quadratus lumborum block. Consistent with the Plan A blocks framework, this decision-making algorithm applies updated nomenclature and consideration of practical factors that influence choice of block by the general anesthesiologist when performing regional analgesia at the point of care.

Abdominal fascial plane blocks are versatile and low-risk additions to a multimodal analgesic regimen for abdominal surgery. Our structured, site-specific, decision-making framework can assist physicians in selecting the most appropriate fascial plane block for abdominal surgery while accounting for patient, surgical, and institutional factors. Such an approach supports individualized analgesic planning and may enhance postoperative recovery, particularly when neuraxial techniques are unsuitable or unavailable.