Rectus Sheath Research Articles

OC-122 CHARACTERISATION OF HUMAN POSTERIOR RECTUS SHEATH REVEALS MECHANICAL AND STRUCTURAL ANISOTROPY

Abstract Background Our work investigated the mechanical properties of the posterior rectus sheath (PRS) in terms of its ultimate tensile stress (UTS), stiffness, thickness and anisotropy as well as assess the collagen fibre organisation of the PRS using Second-Harmonic Generation (SHG) microscopy. Methods For mechanical analysis, twenty-five fresh-frozen PRS samples of were taken from six different cadaveric donors. They underwent uniaxial tensile stress testing until rupture either in the transverse (n=15) or longitudinal (n=10) plane. The thickness of each sample was also recorded using digital callipers. On a separate occasion, ten PRS samples and three anterior rectus sheath samples underwent SHG microscopy and photography to assess collagen fibre organisation. Results PRS samples had a mean UTS of 7.7MPa (SD 4.9) in the transverse plane and 1.2 MPa (SD 0.8) in the longitudinal plane (P<0.01). The same samples had a mean Youngs modulus of 11.1 MPa (SD 5.0) in the transverse plane and 1.7 MPa (SD 1.3) in the longitudinal plane (P<0.01). The mean thickness of the posterior rectus sheath was 0.51mm (SD 0.13). Collagen fibres within the tissue could be identified with SHG microscopy, generally aligned transversely. Conclusion The PRS displayed mechanical and structural anisotropy with greater tensile stress and stiffness in the transverse plane compared to the longitudinal plane. The mean thickness of this layer is around 0.51mm – consistent with other studies. The tissue is constructed of transversely aligned collagen fibres that are visible using SHG microscopy.

OC-089 A CHALLENGING REPAIR OF RECURRENT VENTRAL HERNIA IN A PATIENT WITH A PREVIOUS INTRAPERITONEAL MESH AND ABDOMINOPLASTY

Abstract Aim To understand the challenges faced in repair of recurrent ventral hernia in a patient with a previous intraperitoneal mesh and abdominoplasty. Introduction Ventral hernias still represent a great challenge for surgeons, especially if they are recurrent. We present a 54-year-old overweight female with complex surgical history and a recurrent incisional hernia. She had a laparoscopic cholecystectomy and port site hernia which was repaired without a mesh. She later underwent a Roux-en-Y Gastric bypass for obesity and developed another port site hernia in lower epigastrium. The incisional hernia was repaired with an intraperitoneal mesh. Finally, she had an abdominoplasty for cosmetic reasons. She presented to our surgical clinic with a clinically palpable recurrent large incisional hernia. Methods The repair was carefully planned with a CT abdomen confirming a 6 cm defect in the upper midline and a large intraperitoneal mesh with multiple metallic tacks. The surgical procedure was as follows: Midline incision and careful dissection of the sac. The intraperitoneal mesh was identified and removed carefully keeping the posterior rectus sheath and peritoneum intact. A posterior component separation technique was performed. Posterior rectus sheath was closed with interrupted absorbable sutures. A tailored polypropylene mesh was placed in retro-rectus space. The anterior rectus sheath was closed with non-absorbable interrupted sutures. Patient had an uneventful postoperative period and was discharged on the third postoperative day. Conclusion Careful patient selection, detailed preoperative planning and expertise in abdominal wall reconstruction result in a successful repair of complex ventral hernias.

V-046 LIRA (LAPAROSCOPIC INTRACORPOREAL RECTUS APONEUROPLASTY) WITH A MANUAL ROBOTIC LAPAROSCOPIC ARM: TECHNICAL STEPS

Abstract Introduction LIRA (Laparoscopic Intracorporeal Rectus Aponeuroplasty) is a minimally invasive technique for the tension-free repair of incisional hernias from M2 to M4, with low recurrence rate and less postoperative bulging and seroma formation than classic IPOM lap repair. Objective To describe the main steps of the LIRA focusing on the tension-free midline closure. The use of a robotic laparoscopic arm1 improved the surgeon's mobility range and ergonomy, facilitating the procedure. Methods A 42-year-old obese woman (BMI 34 Kg/m2), presented with a recurrent umbilical hernia M3W2, Hernia defect: 6cm.in width, (previous onlay repair with polypropylene mesh in 2020). Access: 3 Trocars at the midaxillary line. Posterior rectus sheaths were divided, and the defect was closed with a running 2/0 barbed suture. Then, the repair was reinforced with a tailored, round-shaped 15 cm. composite mesh2 fixed with a double crown of absorbable tacks3. No drain was used. Results Operating time: 85 minutes. The procedure was performed in an outpatient setting. The postoperative course was uneventful. Follow-up: 9 months. The patient remains asymptomatic and highly satisfied (9/10). No recurrence nor bulging has been observed. Conclusions The LIRA technique allowed a tension-free reconstruction of the abdominal midline when dealing with ventral hernias, without remarkable complications. LIRA provides the advantages of laparoscopic surgery in terms of less postoperative pain, morbidity (e.g. seroma, and less risk of infection), and no bulging. The use of robotized laparoscopic arms facilitates these quite complex procedures.

V-025 ETEP-RS: EXTENDED TOTALLY EXTRAPERITONEAL RIVES-STOPPA TECHNIQUE FOR SMALL VENTRAL HERNIA

Abstract Aim The aim is to describe the laparoscopic surgical technique of eTEP with 3 trocars from the upper port in a 52-year-old male patient who presented 3 small ventral hernias Material & Methods Recently, the surgical technique of ventral hernia repair, Rives-Stoppa e-TEP eventroplasty (eTEP-RS) has been introduced. First, 2 subcostal incisions are made. By introducing the dissector balloon through both retromuscular spaces up to the linea arcuata, the retromuscular space is exposed. Great care must be taken to preserve the neurovascular bundles at semilunar line. A 5mm trocar is placed on the right flank to perfom the epigastric crossover maniobre by incising the medial aspect of rigth posterior sheath. The dissection of the left retromuscular space is performed. The midline dissection is progressed to the retzius, completing the Rives retromuscular space. The hernia sacs are dissected and reduced. Finally, posterior rectus sheaths and the linea alba are sutured with 2/0 absorbable self-locking continuous barb suture and a mesh is placed in the retromuscular space. Results The patient was discharged the next postoperative day with good pain control. To date, he does not present data on hernia recurrence. Conclusions The repair of abdominal wall defects via endoscopic eTEP Rives-Stoppa with three trocars is a feasible and reproducible technique that meets the criteria of ideal open surgery and is safe for the patient. In addition, it offers advantages such as less postoperative pain, less need for analgesia, favors rapid and safe recovery, added to an excellent aesthetic result.

OC-063 REPAIR OF UMBILICAL HERNIAS ASSOCIATED TO DIASTASIS USING LAPAROSCOPIC ENDOSCOPIC EXTRAPERITONEAL STAPLE BASED SUBLAY MESH TECHNIQUE (LEESS)

Abstract Aim Patients with symptomatic umbilical hernia with associated rectus diastasis represent an increasing clinical problem. The objective was to analyze feasibility and safety using a novel surgical approach: laparoscopic extraperitoneal endoscopic staple-based sublay operation (LEESS). Methods Observational study with all patients for patients who underwent LEESS and a minimum follow-up of 1 year. Data was obtained from a prospective mantained database at Herniamed Registry Results 81 patients were operated from January 1, 2016, to June 30, 2020. Mean operative time was 100 (range, 15–200) min and mean length of hospital stay was 5 (range, 1–9) days. The overall 30 days postoperative morbidity was 12.34%: 2 (2.4%) developed a symptomatic subfascial seroma (minor complication); 2 (2.4%), a postoperative bleeding; 2 (2.4%), mild wound infection without mesh infection; and 1 (1.23%) of internal herniation through a defect in the posterior rectus sheath suture line. There were no surgery-related deaths (in-hospital mortality, 0). After a total follow-up of 12 months, 54 patients out of 81 (rate, 69.3%) recorded their information in the registry; 9 (16.7%) reported pain. The ratio of “Pain at rest” (5.6%) was significantly less than preoperatively (58.8%; p<0.001). “Pain during exercise” (11.1%) is significantly less than preoperatively (58.8%; p<0.001). Conclusion The LEESS technique with mesh augmentation appears to be an innovative, minimally invasive, feasible and safe surgical procedure for treatment of patients with symptomatic ventral midline hernia

V-002 Robotic suprapubic eTEP retrorectus repair for incisional hernia

Abstract Aim A retrorectus mesh position is often considered the most suitable for the repair of a midline incisional hernia. The minimal invasive extraperitoneal approach is gaining popularity. Material & Methods A 56-year-old female patient, who had a laparoscopic deroofing of a bile cyst in her history, presented with an incisional midline hernia (EHS M2-M3, width 6.6 cm). Preoperative optimization via dietary instructions reduced her BMI from 40 kg/m2 to a BMI of 35 kg/m2. Results A robotic extraperitoneal approach via suprapubic docking was performed. The patient is positioned supine and flexed for 15° at the level of the spina iliaca. An intraperitoneal trocar is placed to explore the abdomen for adhesions. Three trocars are placed in the suprapubic position in the extraperitoneal plane whereafter the robot is docked. A dissection in the cranial direction is performed in the retrorectus plane by incising both posterior rectus fascia in a symmetric way. A preperitoneal plane behind the linea alba is created. At the level of the hernia defect the hernia sac is opened, and adhesions are freed. Once the retrorectus space is dissected up to the xyphoid, the linea alba is reconstructed with a barbed suture size 0. A self-fixating mesh is placed in the retrorectus position. The posterior layer of the peritoneum is closed. The postoperative course was uneventful. Conclusions We present an extraperitoneal minimal invasive approach to the retrorectus plane allowing for an adequate retrorectus dissection and mesh placement like in a classical Rives-Stoppa repair.

P-046 NOVEL TECHNIQUE TO DISSECT RETRORECTAL SPACE DURING ETEP APPROACH FOR SUPRAUMBILICAL HERNIAS

Abstract Aim Present a modification for the retrorectal dissection during the performance of enhanced view totally extraperitoneal (eTEP) approach for the treatment of supraumbilical hernia associated with rectus diastasis. Material and methods During eTEP, a new approach to access both retrorectal spaces was performed through an infraumbilical incision. First, we made a 2 cm section in the anterior fascia spanning both sides of the linea alba. Therefore, both retrorectal spaces were dissected with the assistance of a balloon trocar. After this maneuver, a structural trocar was inserted, and CO2 was inssuflated. Then 3 suprapubic trocars were inserted: one at the midline, and the other two medial to both semilunaris lines. After trocar placement, and prior to the inferior crossover the anterior rectus fascia of the infraumbilical incision was closed. The surgery was then performed according to the technique described by Daes and Belyansky. Results We have performed this approach in 2 consecutive patients with supraumbilical hernia (M3W1 and M3W2) associated with rectus diastasis. We achieve a complete dissection of the retro-muscular spaces in only one step and from the same location, facilitating the crossover. There were no associated intraoperative or postoperative complications. Conclusion The presented modification of the retrorectal dissection during laparoscopic eTEP for supraumbilical hernias represents a time-saver, safe and feasible alternative for the dissection of retrorectal space during eTEP.

V-013 NEW TECHNIQUE FOR ABDOMINAL WALL GRAFT RETRIEVAL

Abstract Aim show our technique for abdominal wall graft retrieval minimizing warm ischemia time. Material and methods a video report of an abdominal wall graft retrieval (full-thickness) from a female brain death donor. Results better graft perfusion with a lower picnosis in the studied cells. Lower tissue damage in both full-thickness and isolated fascia grafts. Surgical technique: An “house-flap” incision is done as opposed to a conventional cross-line laparotomy. The flap is extended until the inguinal ligament, divided afterwards to gain easier access to the femoral vessels. After abdominal organ dissection, the common iliac arteries are dissected from close to the aortic bifurcation up to the femoral vessels, beyond the origin of the inferior epigastric arteries. After cannulation of the aorta, cava vein and inferior mesenteric vein for the intraabdominal organs, both common iliac arteries are cannulated beyond the origin of external iliac artery. To achieve optimal perfusion of the rectus fascia we have to clamp the artery distal to the origin of the inferior epigastric artery (usually at the level of the femoral artery). The abdominal wall graft perfusion is done simultaneously with all the abdominal organs. Afterwards, we cover the graft with cold pads to avoid direct contact between the ice and the graft. A closure of the donor abdominal wall must be ensured after removing the wall graft. Conclusions our technique has showed better pathological outcomes than those previously published with a lower warm ischemia time of the abdominal wall graft.

V-026 LAPAROSCOPIC TAPP REPAIR: IS IT REALLY FEASIBLE IN A RE-RECURRENT HERNIA?

Abstract Aim Describe a step by step laparoscopic transabdominal preperitoneal (TAPP) repair of a re-recurrent incisional lumbar hernia. Material & Methods This is the case of a 72-year-old man who had a previous traumatic right lumbar hernia initially approached by laparoscopic intra-peritoneal onlay mesh repair (IPOM) and its recurrence approached by open onlay mesh repair. CT-scan revealed a lumbar hernia on the right with a neck size of 40 mm. The hernia sac measured 65 mm and contained part of the right colon inside, without signs of incarceration nor dilated intestinal loops. According to the European Hernia Society classification for incisional abdominal wall hernias, the patient had a lateral hernia (L4 W2). Results Lateral incisional hernias are limited by the inguinal region inferiorly, the costal margin superiorly, the lateral margin of the rectal sheath medially and the lumbar region laterally. Due to their low incidence and the resulting lack of expertise in the treatment of this abdominal wall defect, surgical treatment poses a challenge- Conclusion The repair of a recurrent hernia is a daunting task, even more so of a re-recurrent one. By choosing to perform a TAPP repair, we were able to prove a laparoscopic re-do repair is feasible even faced with weakened tissues and distorted anatomy.

The Isolation, Culture, and Cryopreservation of Human Rectus Sheath Fibroblasts.

The vast majority of pelvic and intra-abdominal surgery is undertaken through at least one incision, through either the linea alba or the rectus sheath. These connective tissue layers are formed from the aponeuroses of the rectus muscles (anterior and posterior rectus sheath) and are vital for the structural integrity of the abdominal wall. Poor healing of these connective tissues after surgery can lead to significant morbidity for patients, who can develop unsightly and painful incisional hernias. Fibroblasts within the rectus sheath are responsible for laying down and remodeling collagen during the healing process after surgery. Despite their importance for this healing process, such cells have not been studied in vitro. In order to carry out such work, researchers must first be able to isolate these cells from human tissue and culture them successfully so they may be used for experimentation. This article provides an extensive and detailed protocol for the isolation, culture, cryopreservation, and thawing of human rectus sheath fibroblasts (RSFs). In our hands, this protocol develops confluent cultures of primary fibroblasts within 2 weeks, and sufficient cultures ready for freezing and storage after a further 2 to 4 weeks. © 2023 The Authors. Current Protocols published by Wiley Periodicals LLC. Basic Protocol: Collagenase digestion of human rectus sheath and isolation of RSFs Alternate Protocol: Collagenase digestion of human rectus sheath and isolation of RSFs, digestion in flask Support Protocol: Cryopreservation and thawing of human RSFs.

Effect of rectus sheath anaesthesia versus thoracic epidural analgesia on postoperative recovery quality after elective open abdominal surgery in a French regional hospital: the study protocol of a randomised controlled QoR-RECT-CATH trial

IntroductionEnhanced recovery after surgery (ERAS) protocols increase patient well-being while significantly reducing mortality, costs and length-of-stay after surgery. A key component is multimodal analgesia that prevents postoperative pain and facilitates...

How I do it: Ultrasound-guided rectus sheath blocks

How I do it: Ultrasound-guided rectus sheath blocks

Management of Chronic Truncal Wall Type-I Complex Regional Pain Syndrome in a Patient with Uncontrolled Diabetes Mellitus: Case Report

Complex regional pain syndrome (CRPS) is a chronic pain syndrome associated with sensory, vasomotor, sudomotor, motor and trophic changes commonly affecting the upper and lower extremities; however, we report a case of truncal wall CRPS in an uncontrolled type 2 diabetes mellitus patient. A male in his late fifties presented with right lower chest and upper abdominal wall burning, sharp and stabbing type of pain for 5 years associated with hyperalgesia and allodynia. The extensive evaluation ruled out any underlying pathology and the symptoms were increasing with time. He failed to respond to conservative pharmacological, non-pharmacological treatment and rehabilitation measures. In our institute, he underwent alcohol neurolysis of subcostal transversus abdominis plane and rectus sheath nerves with rehabilitation measures and reported significant relief in his symptoms. It has now been 6 months since the procedure was done and he has complete relief in pain. Hence, if sympathetic block is difficult to do, peripheral nerve block with alcohol and rehabilitation measures provide desirable effect in abdominal wall CRPS.

Evaluation of Reducing the Excess Abdominal Skin, Subcutaneous Tissue and Anterior Abdominal Wall Laxity: A Prospective Observational Study at Dhaka Medical College Hospital

Background: Lax abdominal muscles cause laxity or bulging. This is generally a consequence of age or post-pregnancy, causing the abdominal rectus muscles and fascia that overlies and divides them to weaken. Abdominoplasty, a popular cosmetic surgery, has improved in recent years. helped minimize abdominal fat and skin. Medical institutions are diagnosing and treating obesity at an increasing pace. Objective: The purpose of the study was reduce the excess abdominal skin,subcutaneous tissue and anterior abdominal wall laxity. Methods: The duration of this prospective observational research was from July 2014 to April 2015. The research population consisted of patients hospitalized to the Plastic Surgery Department of Dhaka Medical College Hospital and numerous private hospitals in Dhaka with extra abdominal skin and abdominal wall laxity owing to various causes, such as past pregnancy or severe weight loss. From the study population, 30 instances that satisfied the enrollment requirements were chosen. Results: The majority of patients (26, or 86.67 %) were female, and 76 % were married. At the time of surgery, the average age was 41.3 years. The total complication rate was 40%, with just four serious complications (13.33%) and the most being mild (9, 30 % ). Seroma (3, 10%), infection (2, 6.67%), hematoma (2, 6.67%), wound dehiscence (1, 3.33%), partial flap loss (2, 6.67%), umbilical stenosis (1, 3.33%), epidermolysis (1, 3.33%), DVT (1, 3.33%) were the most prevalent complications (1, 3.33 % ). Very excellent (19, 66.3%), good (9, 30%), and adequate were patients' ratings of satisfaction (2, 6 % ). No patient reported low or extremely bad satisfaction. Conclusion: Abdominoplasty may be done with little risk and provides excellent results. Patients reported relief from their symptoms and satisfaction with the result. However, there was a high rate of mild problems, most of which involved wound healing. At most cases, problems were mild and quickly treated in a doctor's office.

Rectus Sheath Block Improves Patient Recovery Following Open Aortic Surgery

Postoperative pain management remains a barrier to recovery following aortic surgery. Although epidural catheters help in adjunctive pain management, less is known about the use of rectus sheath blocks. We compared patient recovery following open abdominal aortic surgery (OAS) with and without adjunctive rectus block. Adult patients undergoing open abdominal aortic aneurysm repair and aortobifemoral or aortoiliac bypass for occlusive disease were identified and stratified by use of general anesthesia alone (GA) versus adjunctive use of a rectus sheath block (GA+RB). A small number of patients with GA and concomitant epidural analgesia, along with patients that had retroperitoneal repairs, were not included in further analysis. Outcomes included time to extubation, intraoperative and postoperative morphine milligram equivalents (MME) utilization, length of stay, discharge MME, and postoperative complications. Categorial data were compared with Person Chi-Square tests or Fisher's exact tests. Continuous data were tested with independent t-tests or Mann-Whitney U-tests. From January 2017 to April 2022, there were 106 patients who underwent open aortic surgery, 55 patients with GA alone, 39 with GA+RB, and 12 patients who had a GA with concomitant epidural analgesia. Between GA and GA+RB, patients were comparable in both groups in terms of age, BMI (body mass index), smoking history, hypertension, diabetes, CAD (coronary artery disease), COPD (chronic obstructive pulmonary disease), and ASA (American Society of Anesthesiologists) class and prior opioid use. Patients with GA+RB were more likely to have scheduled elective procedures (80% GA cohort vs. 94.9% RB, P=0.040), and a lower incidence of retroperitoneal exposure (14.5% GA cohort vs. 0% RB, P=0.019). Patients with GA+RB had shorter time to extubation than GA (84.6%<12hr vs. 44.4%, P<0.001), greater rate of procedural ketamine usage (GA+RB: 61.5% vs. GA: 40.0%, P=0.049), lower MME at first postoperative day (median MME GA+RB: 25.0 vs. GA: 67.5, P=0.002), lower discharge MME (median MME GA+RB: 142.5 vs. GA: 225.0, P=0.036), and overall shorter length of stay (median stay GA+RB: 5 vs. GA: 6days, P=0.006). Postoperative complications were similar between groups. Similar findings were found in the comparison between elective-only GA and GA+RB patients and after exclusion of patients who only had a single shot of regional anesthesia. Patients that receive adjunctive rectus sheath blocks for pain control following OAS utilize fewer opioid medications during hospital stay and at discharge. Rectus sheath blocks represent an alternative option to other periprocedural analgesia following open aortic surgery.

Intraarterial embolizations in life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH): a three-center experience

PurposeTo retrospectively evaluate the technical and clinical success of interventional treatments employed in three University medical centers and to develop work-flow recommendations for intra-arterial embolizations in patients with life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH).Materials and methodsRetrospective evaluation of all patients with contrast-enhanced CT and digital subtraction angiography (DSA) for SRRSH from 01/2018 to 12/2022, amounted to 91 interventions in 83 patients (45f, 38m) with a mean age of 68.1 ± 13.2 years. Analysis of the amount of bleeding and embolized vessels, choice of embolization material, technical success, and 30-day mortality was performed.ResultsPre-interventional contrast-enhanced CT demonstrated active contrast extravasation in 79 cases (87%). DSA identified a mean of 1.4 ± 0.88 active bleeds in all but two interventions (98%), consisting of 60 cases with a singular and 39 cases of >1 bleeding artery, which were consecutively embolized. The majority of patients underwent embolization with either n-butyl-2-cyanoacrylate (NBCA; n=38), coils (n=21), or a combination of embolic agents (n=23). While the technical success rate was documented at 97.8%, 25 patients (30%) died within 30 days after the initial procedure, with mortality rates ranging from 25 to 86% between the centers, each following different diagnostic algorithms.ConclusionEmbolotherapy is a safe therapy option with high technical success rates in patients with life-threatening SRRSH. To maximize clinical success and survival rates, we propose a standardized approach to angiography as well as a low threshold for re-angiography.

Bilateral transversus abdominis plane and rectus sheath blocks with liposomal bupivacaine for patients undergoing robotic prostatectomy.

As robotic prostatectomy surgery becomes more prevalent, it is important to identify any regional techniques to optimize patient's recovery. We evaluated the effectiveness of bilateral transversus abdominis plane (TAP) and rectus sheath (RS) blocks with liposomal bupivacaine. We hypothesized that these blocks would reduce perioperative opioid use and pain scores. A retrospective cohort of patients from May 2018 and May 2021 at a single large VA hospital were studied. We compared those not receiving a nerve block against those receiving the TAP and RS as part of an Enhanced Recovery After Surgery (ERAS) pathway starting in May 2019. The primary outcome was post-operative opioid use. Secondary outcomes were post-operative pain scores and hospital length of stay. One hundred and thirty-four patients were included in the final analysis. Eighty-one patients did not receive a block and fifty-three patients did receive a block. No difference existed between the groups in regard to median oral morphine equivalents (mg) used in PACU or any post-operative day. No difference existed in median opioid usage (mg) or pain scores between the two groups on any post-operative day. There was no difference in temporal association of median pain scores or narcotic usage between the two groups. Bilateral TAP and RS with liposomal bupivacaine did not significantly decrease post-operative opioid use, improve pain scores, or decrease hospital length of stay for patients undergoing robotic prostatectomy. Further studies need to be done to evaluate the effect of these blocks with liposomal bupivacaine.

Comparison of Ultrasound-Guided Rectus Sheath Block Versus Local Infiltration at The Port Sites and Intraperitoneal Instillation of 0.25% Bupivacaine for Post-Operative Pain Control After Laparoscopic Cholecystectomy

Comparison of Ultrasound-Guided Rectus Sheath Block Versus Local Infiltration at The Port Sites and Intraperitoneal Instillation of 0.25% Bupivacaine for Post-Operative Pain Control After Laparoscopic Cholecystectomy

A COMPARISON OF PRE-EMPTIVE ANALGESIA WITH INTRAPERITONEAL INSTILLATION OF ROPIVACAINE VERSUS ULTRASOUND GUIDED RECTUS SHEATH BLOCK IN LAPROSCOPIC CHOLECYSTECOMY:

Background and Aims: Laparoscopic cholecystectomy replaced open surgery as preferred method. The largest component of pain is incisional pain (50 to 70%). Rectus sheath block acts at terminal branches of intercostal nerves in the space between rectus abdominis muscle and posterior rectus sheath resulting in anaesthesia of the midline. While intraperitoneal instillation blocks the visceral nociceptive conduction from area of tissue damage and peritoneum.The aim of this study was to evaluate the efficacy of intraperitoneal instillation versus rectus sheath block using ropivacaine for postoperative pain relief for laparoscopic cholecystectomy. After written informed consent 30 a Methods: dult ASA I,II patients were randomised into 3 groups of 10 patients. Group C (control) received only rescue analgesic on pain, Group I (Intraperitoneal instillation) received 0.25% ropivacaine 40 ml before surgery, Group R (Rectus sheath block) received bilateral block with 30 ml of 0.25% ropivacaine before surgery. -compare the VAS at Primary objective 2nd,4th,6th,12th,24th,48 hours. -assess time for 1st rescue analgesia and tramadol consumption Secondary objectives in first 6 hours. The demographic data were comparable. VAS scores at various intervals were lower Results: in both group R and group I compared to C ( p-&lt;0.05). VAS in group R was significantly lower than group I (p value &lt;0.05).Total tramadol consumption was lower in group R compared to I and C (p 0.0002). The first rescue analgesia was significantly later in group R (p 0.0005)

Ultrasound-Guided Transversus Abdominis Plane (TAP) Blocks Vs. Local Infiltration Anesthesia on Post Anesthesia Care Unit (PACU) Pain Control

Abstract Goals/Purpose Ultrasound-guided regional field blocks are not widely used in outpatient plastic surgery.1 These blocks have been shown to significantly decrease the number of prescribed opioids in patients who underwent abdominoplasty, liposuction, and primary submuscular breast operations. 2,3 The goal of this study is to compare ultrasound-guided TAP blocks to local infiltration anesthesia with or without blind rectus sheath blocks in patients undergoing abdominoplasty. Methods/Technique A retrospective review was conducted of patients undergoing outpatient abdominoplasty performed by the senior surgeon. Group 1 (Local) received local infiltration anesthesia with or without blind rectus sheath blocks between April 2009 and December 2013. Group 2 (TAP) received surgeon-led, intraoperative, ultrasound-guided, 4-quadrant TAP blocks between January 2014 and December 2021. Outcomes measured included opioid utilization, morphine milligram equivalents (MME) and pain level at discharge (scale from 1 to 10). All abdominoplasties were performed using the same suture materials and techniques by the senior surgeon in the same accredited outpatient surgical facility. Abdominoplasty technique included supraumbilical undermining, umbilical transposition, rectus abdominis fascial plication, progressive tension sutures, and liposuction of the flanks. Patients were excluded if other procedures were performed at the time of abdominoplasty. Results/Complications 60 patients in each of the two study groups met the study criteria for a total of 120 patients. The study groups were similar except for a lower average age in group 1 (Table 1). Patients receiving TAP blocks (group 2) had significantly lower MME requirements in the PACU (3.48 v 2.21, p=0.005). There was no difference in pain level at discharge between the two groups (2.35 v 2.17, p=0.624), (Table 1). Conclusion Surgeon-led, intraoperative, ultrasound-guided, 4-quadrant TAP blocks statistically significantly reduced opioid utilization by 36.5% in the PACU while achieving comparable patient pain scores.