Four-quadrant Transversus Abdominis Plane Block as the Primary Anesthetic Technique for Umbilical Hernia Repair in a Patient with Decompensated Liver Disease with Tense Ascites: A Case Report

REPORThernial site.He was a known case of chronic liver disease with portal hypertension and gross ascites for the past 3 years.His Child-Pugh score was calculated to be 11 (Child Class C).He underwent regular ascitic tapping at an interval of 15-20 days, with 5-8 L of fluid drained in every sitting.He was admitted with a history of hepatic encephalopathy with acute kidney injury 2 months back. IntroductIonAny surgical procedure in a case of decompensated liver disease with tense ascites, gross coagulation derangement, and recovering from encephalopathy is a major challenge for both the surgeon and anesthetist.Additionally, airway difficulty warranting bronchoscopic nasal intubation may multiply the difficulty due to the risk of intranasal bleeding.Such a case (Child Class C, Child-Pugh score 11) presenting for umbilical hernia repair for ascitic leak was successfully conducted under transversus abdominis plane (TAP) block, multiple-site injection approach, and minimal sedation.The procedure was well tolerated by the patient, and hemodynamic stability was remarkable.The patient was discharged after 6 days of hospital stay without any further complications.Effective use of ultrasound (USG)-guided regional plane block helped in avoiding many of the dreaded complications, often with mortality, associated with general anesthesia or neuraxial anesthesia. case descrIptIonA 46-year-old male with a history of decompensated chronic liver disease with gross ascites was scheduled for elective open umbilical hernia repair due to persistent ascitic leakage at the 1-