Open inguinal hernia repair under combined transversalis fascia plane and transversus abdominis plane blocks in a high-risk cardiac patient

Selecting an optimal anesthetic technique for inguinal hernia repair is particularly challenging in patients with severe cardiac comorbidities and ongoing anticoagulant therapy. General anesthesia may increase cardiopulmonary instability, whereas neuraxial techniques carry risks of hypotension and bleeding complications. We report the case of a 76-year-old man with advanced heart failure (ejection fraction 20%), New York Heart Association (NYHA) class III symptoms, pacemaker dependency, and chronic warfarin therapy who underwent elective open right inguinal hernia repair. Ultrasound-guided unilateral transversalis fascia plane (TFP) block (30 mL of 0.25% bupivacaine) combined with a transversus abdominis plane (TAP) block (20 mL of 0.25% bupivacaine) was performed as the sole anesthetic technique. Adequate sensory blockade over T12–L1 dermatomes was achieved within 20 minutes. Surgery using the Lichtenstein technique was completed in 45 minutes with stable hemodynamic parameters, without the need for conversion to general anesthesia, surgical infiltration, or intraoperative opioid supplementation. Postoperative pain was well controlled with multimodal non-opioid analgesia, with numerical rating scale (NRS) scores ≤2 during the first 24 hours. No rescue opioid analgesia was required. The patient had an uneventful recovery and was discharged on postoperative day 2. The combination of transversalis fascia plane and TAP blocks may represent a feasible and effective anesthetic alternative for open inguinal hernia repair in carefully selected high-risk cardiac patients in whom general or neuraxial anesthesia is undesirable.