Rectus Sheath Block Research Articles

Comparing two different techniques of rectus sheath block after single port laparoscopic surgery in benign adnexal mass patients: Surgical versus ultrasonography guidance—A randomized, single-blind, case-controlled study

ObjectiveThe purpose of this study was to compare the analgesic effect of surgical bilateral rectus sheath block (BRSB) and ultrasonography-guidance BRSB in patients undergoing single port laparoscopic surgery (SPLS) for ovarian cyst. Study designSeventy-five patients were randomly allocated into three groups: the control and ultrasound (US)-guidance group (n=25, each) received BRSB with 10ml of normal saline or 0.5% ropivacaine bilaterally under US guidance at the end of surgery, respectively; the surgical group (n=25) received BRSB with10ml of 0.5% ropivacaine bilaterally just before suturing the surgical site. All patients received intravenous fentanyl 50μg for postoperative pain before emergence from anesthesia. Additional self-administered fentanyl and pain intensity were measured at postoperative 1, 6, 10 and 24h. ResultsDemographic characteristics showed no significant group-wise differences. The cumulative amount of fentanyl delivered was significantly lower in the US-guidance and surgical BRSB groups (189.20μg and 187.68μg, respectively) than the control group (286.40μg) on postoperative day 1 (P<0.001). At 24h, the median pain score was significantly lower only in the surgical BRSB group. In addition, opioid-related side effects were decreased in patients who received BRSB (control group 36% vs. US-guidance BRSB group 24% vs. surgical BRSB group 12%). ConclusionsBoth US-guided and surgical BRSB were effective for pain control in patients undergoing SPLS. Thus, surgical BRSB can be performed by gynecologists intra-operatively, for post-operative pain management.

Systematic Review of the Systemic Concentrations of Local Anaesthetic After Transversus Abdominis Plane Block and Rectus Sheath Block

(Abstracted from Br J Anaesth, 118(4):517–526, 2017) This systematic review aimed to assess data from clinical trials to determine perioperative local anesthetic (LA) systemic concentrations following single-bolus transversus abdominis plane block (TAPB) or rectus sheath block (RSB) during abdominal surgery in order to improve our understanding of LA absorption and risk of toxicity following these blocks.

Use of Regional Anesthesia Techniques: Analysis of Institutional Enhanced Recovery After Surgery Protocols for Colorectal Surgery.

Principles of Enhanced Recovery After Surgery (ERAS®) protocols are well established, with the primary goal of optimizing perioperative care and recovery. The use of multimodal analgesia is a key component of these protocols, including regional analgesia techniques such as thoracic epidural analgesia (TEA), transversus abdominis plane (TAP), rectus sheath blocks or continuous wound infiltration (CWI)/catheters, and spinal anesthesia. We compare and contrast regional anesthesia approaches in different institutional colorectal surgery ERAS protocols. ERAS protocols for open and laparoscopic colorectal surgery were obtained from 15 different healthcare facilities mostly located in North American and one in New Zealand. A comparison was then made with respect to regional anesthesia recommendations. The most commonly used regional technique among protocols was TEA. TAP blocks were the next most common, with rectus sheath blocks and continuous wound catheters only mentioned in one protocol each. There are both similarities and differences in regional anesthesia techniques, which may be due to institution- and provider-level factors. Most protocols advocate for TEA use, which has been associated with a lower incidence of paralytic ileus, attenuation of the surgical stress response, improved intestinal blood flow, improved analgesia, and reduction of opioid use. Use of spinal anesthesia may lead to earlier mobilization compared to TEA, and lower doses of intrathecal morphine are recommended to reduce respiratory depression. TAP blocks were indicated for laparoscopic procedures. Rectus sheath blocks, which are listed in some protocols, may provide analgesia equivalent to epidural anesthesia, while avoiding complications of TEA. CWI has been effective in reducing postoperative pain, hastening recovery, and improving pulmonary function.

Ultrasound-guided para-umbilical block: a pediatric case

BackgroundRectus sheath block is a common peripheral nerve block for patients undergoing umbilical hernia repair surgery. However, rectus sheath block alone can affect only anterior branches of intercostal nerves and, therefore, is incomplete for postoperative analgesia for the anterior abdomen, which is innervated by both anterior and lateral branches. We describe a successful perioperative analgesia with ultrasound-guided para-umbilical block after pediatric umbilical hernia surgery.Case presentationA 4-year-old child underwent hernia repair surgery. Following induction of general anesthesia, the anatomy of the umbilical region was observed under ultrasound with a 5–10-MHz linear probe. An ultrasound-guided injection between the rectus abdominis muscle and the posterior lobe of the rectus sheath and an injection into the subcutaneous space around the umbilicus were performed. The peripheral nerve block was effective during surgery, and the patient required no additional rescue analgesia during the perioperative period. There were no complications.ConclusionWe performed ultrasound-guided para-umbilical block with four injections. This peripheral nerve block could be an efficient technique for complete perioperative analgesia.

Ultrasound-guided bilateral rectus sheath block vs. conventional local analgesia in single port laparoscopic appendectomy for children with nonperforated appendicitis

IntroductionDespite its minimally invasive approach, laparoscopic surgery can cause considerable pain. Regional analgesic techniques such as the rectus sheath block (RSB) offer improved pain management following elective umbilical hernia repair in the pediatric population. This effect has not been examined in laparoscopic single-incision surgery in children. We sought to compare the efficacy of bilateral ultrasound-guided RSB versus local anesthetic infiltration (LAI) in providing postoperative pain relief in pediatric single-incision transumbilical laparoscopic assisted appendectomy (TULA) with same-day discharge. MethodsWe retrospectively reviewed 275 children, ages 4 to 17 years old, who underwent TULA for uncomplicated appendicitis in a single institution from August 2014 to July 2015. We compared those that received preincision bilateral RSB (n=136) with those who received LAI (n=139). The primary outcome was narcotic administration. Secondary outcomes included initial and mean scores, time from anesthesia induction to release, operative time, time to rescue dose of analgesic in the PACU and time to PACU discharge. ResultsTotal narcotic administration was significantly reduced in patients that underwent preincision RSB compared to those that received conventional LAI, with a mean of 0.112 mg/kg of morphine versus 0.290 mg/kg morphine (p<0.0001). Patients undergoing RSB reported lower initial (0.38 vs. 2.38; p<0.0001) and mean pain scores (1.26 vs. 1.77; p<0.015). Time to rescue analgesia was prolonged in patients undergoing RSB compared to LAI (58.93min vs. 41.56min; p=0.047). ConclusionPreincision RSB for TULA in uncomplicated appendicitis in children is associated with decreased opioid consumption and lower pain scores compared with LAI. As the addition of this procedure only added 6.67min to time under anesthesia, we feel that it is a viable option for postoperative pain control in pediatric single-incision laparoscopic surgery. Retrospective comparative studyLEVEL III EVIDENCE.

Efficacy of US-guided transversus abdominis plane block and rectus sheath block with ropivacaine and dexmedetomidine in elderly high-risk patients.

This study was designed to evaluate the effectiveness and safety of ultrasound-guided transversus abdominis plane (TAP) and rectus sheath (RS) blocks with ropivacaine and dexmedetomidine in elderly, high-risk patients undergoing emergency abdominal surgery. Sixty elderly patients undergoing emergency abdominal surgery receiving both bilateral ultrasound-guided TAP and RS blocks were randomly divided into two groups: R+D (10 mL of 0.25% ropivacaine+0.5μg/kg dexmedetomidine) and R (10 mL of 0.25% ropivacaine). Pain scores (at rest and with movement) and overall analgesia satisfaction were assessed. The total amount of sufentanil administered postoperatively during the first 24 h, duration of sensory blockade, first time and total number of patient-controlled intravenous analgesia (PCIA) pump activations on the first postoperative day were recorded. The duration of sensory blockade and the first time to PCIA pump activation in the R+D group were longer than that of the R group (P<0.05). The total number of PCIA pump activations on the first postoperative day as well as the total amount of sufentanil administered during the first 24 h in R+D group were less than in the R group (P<0.05). VAS scores at rest and during activity in the R+D group were lower than those in the R group at 2, 6, and 12 h after surgery (P<0.05). Ultrasound-guided TAP and RS blocks with ropivacaine and dexmedetomidine are more effective in promoting block effect, prolonging the duration of analgesia, reducing postoperative pain in elderly high-risk patients undergoing emergency abdominal surgery.

A novel transperitoneal abdominal wall nerve block for postoperative pain in laparoscopic colorectal surgery

Although the laparoscopic approach reduces pain associated with abdominal surgery, postoperative pain remains a problem. Ultrasound-guided rectus sheath block and transversus abdominis plane block have become increasingly popular means of providing analgesia for laparoscopic surgery. Ninety patients were enrolled in this study. A laparoscopic puncture needle was inserted via the port, and levobupivacaine was injected into the correct plane through the peritoneum. The patients' postoperative pain intensity was assessed using a numeric rating scale. The effects of laparoscopic nerve block versus percutaneous anesthesia were compared. This novel form of transperitoneal anesthesia did not jeopardize completion of the operative procedures. The percutaneous approach required more time for performance of the procedure than the transperitoneal technique. This new analgesia technique can become an optional postoperative treatment regimen for various laparoscopic abdominal surgeries. What we mainly want to suggest is that the transperitoneal approach has the advantage of a higher completion rate. A percutaneous technique is sometimes difficult with patients who have severe obesity and/or coagulation disorders. Additional studies are required to evaluate its benefits.

Development of a novel technique for bilateral rectus sheath nerve blocks under laparoscopic-guidance

BackgroundBilateral rectus sheath blocks have proven to be superior to local anesthetic infiltration for umbilical incisions and have been gaining popularity for the treatment of perioperative pain in children. We aim to develop a technique of surgeon performed rectus sheath blocks under laparoscopic-guidance alone. MethodsIn phase I, we observed the laparoscopic appearance of a rectus sheath block. The pain management team performed an ultrasound-guided rectus sheath nerve block as we visualized the posterior rectus sheath with the laparoscope. In phase II, after completion of the laparoscopic procedure, we performed a rectus sheath nerve block. Ultrasound was used to identify where the local anesthetic had been injected. ResultsNineteen patients were included in this study, accounting for 38 rectus sheath blocks. In phase I, we observed with the laparoscope the delivery of ten ultrasound-guided rectus sheath blocks. In phase II, 28 laparoscopic-guided rectus sheath blocks were completed with immediate ultrasound confirmation of correct placement. ConclusionsWe have demonstrated that the rectus sheath nerve block can be performed reliably under laparoscopic-guidance alone. The efficacy of the laparoscopic-guided nerve block compared to the ultrasound-guided approach will need further study in a prospective, randomized trial. Type of studyRetrospective review. Level of evidence3.

Percutaneous ultrasound-guided vs. intraoperative rectus sheath block for pediatric umbilical hernia repair: A randomized clinical trial

BackgroundRegional anesthesia is commonly used in children. Our hypothesis was that percutaneous ultrasound-guided (PERC) rectus sheath blocks would result in lower postoperative pain scores compared to intraoperative (IO) rectus sheath blocks following umbilical hernia repair. MethodsA single-institution randomized blinded trial was conducted in pediatric patients undergoing elective umbilical hernia repair. The primary outcome was mean postoperative Wong–Baker pain score. Secondary outcomes included narcotic requirements and length of postoperative stay. ResultsFifty-eight patients were included: 28 PERC and 30 IO. Operating room time was significantly longer in the PERC group (41 vs. 35min, p<0.01). Mean postoperative pain scores (PERC-2.6 vs. IO-3.3, p=0.11), morphine equivalents intraoperatively (PERC-0 vs. IO-0.04mg/kg, p=0.29) and postoperatively (PERC-0.04 vs. IO-0.09mg/kg, p=0.17), time to first postoperative narcotic dose (PERC-30 vs. IO-22min, p=0.33, log-rank test), and postoperative length of stay (PERC-76 vs. IO-80min, p=0.44) were similar. ConclusionFollowing umbilical hernia repair in children, percutaneous ultrasound-guided and intraoperative rectus sheath blocks resulted in similar mean postoperative pain scores. There were no differences in secondary outcomes such as time to first narcotic, narcotic requirements, and length of stay. The additional resources required to complete a percutaneous ultrasound-guided rectus sheath block may not be warranted. Type of studyRandomized controlled trial. Level of evidenceLevel I.

Anterior rectus sheath blocks in children with abdominal wall pain due to anterior cutaneous nerve entrapment syndrome: a prospective case series of 85 children.

Chronic abdominal pain in children may be caused by the anterior cutaneous nerve entrapment syndrome. Local nerve blocks are recommended as an initial treatment in adults. Evidence on effectiveness and safety of such a treatment in children is lacking. Our aim was to study outcome and adverse events of anterior rectus sheath blocks in childhood anterior cutaneous nerve entrapment syndrome. Patients <18 years of age receiving anterior rectus sheath blocks were prospectively followed. Injections were administered using a free-hand technique in the outpatient department. A total of 85 children were included (median age 15 years, range 8-17, 76% female). Eighty-three children reported immediate pain relief following a single lidocaine block and 13 achieved long-term success. Another 19 children was successfully treated with additional blocks combined with steroids. A total 38% success ratio was attained after a median 17-month follow-up (range, 4-39). Pain intensity and diagnostic delay were not associated with a beneficial outcome. However, young age predicted success. An infrequently occurring adverse event was temporarily increased pain some 6 h post injection. Anterior rectus sheath blocks using local anesthetics and steroids are safe and long-term successful in more than one-third of children suffering from abdominal pain due to anterior cutaneous nerve entrapment syndrome.

Does Rectus Sheath Block Analgesia Alter Levels of the Oxidative Stress Biomarker Glutathione Peroxidase: A Randomised Trial of Patients with Cancer and Benign Disease.

To evaluate whether the overall satisfaction, as measured by numeric rating scale (NRS), regarding rectus sheath block (RSB) analgesia is associated with the plasma glutathione peroxidase (GPX1) level. The second end-point of the study was to evaluate the differences in GPX1 levels in patients with and without RSB analgesia, with special emphasis on benign or malign disease status. Initially, 56 patients were randomized to the placebo group (n=12) and to one of three active RSB analgesia groups: single-dose (n=16), repeated-dose (n=12) and continuous infusion (n=16) groups. The plasma level of GPX1 was measured at three time points: just before, immediately after and 24 h after surgery. The overall satisfaction and an opinion on the success of the analgesic procedure were surveyed using an 11-point numeric rating scale 24 h postoperatively (NRS from 0, completely dissatisfied, to 10, fully satisfied). The placebo group and the three active groups were similar in terms of their perioperative data. The plasma level of GPX1 decreased postoperatively in all four groups. No differences were detected in the GPX1 values between the placebo and the three active groups combined preoperatively and immediately after operation. However, the patients in the single-dose group had a significantly lower median GPX1 values 24 h after surgery compared to the three other groups separately (p=0.032). The median (interquartile range) plasma level of GPX1 differed significantly between patients with benign disease and those with cancer preoperatively (18.0, 12.5-22.0 versus 10.0, 6.3-18.8 pg/ml, p=0.006) and cancer diagnosis was correlated with lower individual plasma GPX1 values (r=-0.42, p=0.004). The placement of RSB analgesia does not significantly affect the level of oxidative stress biomarker GPX1 in patients with benign disease or cancer. A new finding with possible clinical relevance is that patients with cancer appeared to have a trend for lower plasma GPX1 values.

Laparoscopic-assisted Rectus Sheath Block as a Novel Technique is Effective and Safe: A Randomized Controlled Trial.

We developed laparoscopic-assisted rectus sheath block (LRSB) as a novel technique and report on its safety and effectiveness. Patients were randomly enrolled to an LRSB or control group (n=19 each). In the LRSB group, after the umbilical wound was closed, local anesthetic was injected transcutaneous at each of 4 sites (3 cm above and below the umbilicus bilaterally) with 10 mL of 0.25% levobupivacaine, laparoscopically. The control group received conventional postoperative pain management. The primary endpoint was visual analogue scale (VAS) pain score at the end of surgery. Secondary endpoints were VAS and Prince Henry pain scale after surgery, number of administrations of analgesics, and side effects of anesthesia. No significant differences in background were seen between groups. VAS at the end of surgery was significantly lower in the LRSB group than in controls (P<0.01). VAS and Prince Henry pain scale were significantly lower in the LRSB group from soon after surgery to postoperative day 2. No complications related to LRSB were encountered. LRSB was particularly effective at the end of surgery and pain scores were significantly lower in the LRSB group long after surgery. Our study shows LRSB is effective and safe for laparoscopic abdominal surgery.

Local Anaesthetic Myotoxicity Due to Fascial Plane Blocks: A Brief Review

Fascial plane blocks have become quite popular in the present practice of regional anaesthesia. Transverses abdominal plane (TAP) block, quadratus lumborum (QL), serratus anterior plane (SAP) block, pectoralis block (PECS 1/ 2), rectus sheath and adductor canal block are quite easy to perform with ultrasonographic (USG) guidance.

The efficacy of rectus sheath block for pain management following laparoscopic orchiopexy surgery

Background Ultrasound (U/S)-guided rectus sheath block is an effective analgesic technique in elective pediatric laparoscopic surgical procedures. The aim of the study was to evaluate the efficacy of rectus sheath block for pain management following laparoscopic orchiopexy surgery. Patients and methods A total of 50 patients undergoing elective laparoscopic orchiopexy were allocated randomly into two groups: the U/S-guided rectus sheath block group (the REC group) and the general anesthesia-only group (the GA group), in which no rectus sheath block was performed. All patients received the same general anesthetic technique. In the REC group, patients received bilateral U/S-guided rectus sheath block, using 0.4 ml/kg of 0.25% bupivacaine, and morphine (0.1 mg/kg) was administered for rescue analgesia postoperatively and its total dose was recorded. Pain was measured by means of Children’s Hospital of Eastern Ontario Pain Scale score. Hospital stay and the incidence of respiratory depression or vomiting were recorded. Results In all, 50 patients completed the study. The total dose of morphine used over 24 h was significantly lower in the REC group. Children’s Hospital of Eastern Ontario Pain Scale scores were significantly lower in the REC group during the first 3 h postoperatively, and the incidence of vomiting, respiratory depression, and oxygen saturation in the postanesthesia care unit showed no significant difference between the study groups. Hospital stay was significantly shorter in the REC group compared with the GA group. Conclusion U/S-guided rectus sheath block is an effective analgesic technique with morphine-sparing effect after laparoscopic orchiopexy surgery.

Essentials of Our Current Understanding: Abdominal Wall Blocks.

Abdominal wall blocks rely on the spread of local anesthetic within musculofascial planes to anesthetize multiple small nerves or plexuses, rather than targeting specific nerve structures. Ultrasonography is primarily responsible for the widespread adoption of techniques including transversus abdominis plane and rectus sheath blocks, as well as the introduction of novel techniques such as quadratus lumborum and transversalis fascia blocks. These blocks are technically straightforward and relatively safe and reduce pain and opioid requirements in many clinical settings. The data supporting these outcomes, however, can be inconsistent because of heterogeneity of study design. The extent of sensory blockade is also somewhat variable, because it depends on the achieved spread of local anesthetic and the anatomical course of the nerves being targeted. The blocks mainly provide somatic analgesia and are best used as part of a multimodal analgesic regimen. This review summarizes the anatomical, sonographic, and technical aspects of the abdominal wall blocks in current use, examining the current evidence for the efficacy and safety of each.

Efficiency and safety of bilateral ultrasound rectus sheath block in urgent laparotomy

58 patients who underwent urgent laparotomy were included in this randomized controlled study. The efficacy and safety of bilateral ultrasound rectus sheath block of ropivacaine with systemic analgesia in comparison with only systemic analgesia were assessed. Rectus sheath block reduces the pain intensity and the consumption of opioids and declines the incidence of the adverse effects, therefore improving the quality of analgesia and postoperative comfort ofpatient.

The Efficacy of Laparoscopic Rectus Sheath Block for Postoperative Pain After Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) in Pediatric Outpatient Surgery

The Efficacy of Laparoscopic Rectus Sheath Block for Postoperative Pain After Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) in Pediatric Outpatient Surgery

Comparative Study of Ultrasound Guided Modified Rectus Sheath Block With Conventional Post-Operative Analgesia in Lower Abdominal Surgeries

Comparative Study of Ultrasound Guided Modified Rectus Sheath Block With Conventional Post-Operative Analgesia in Lower Abdominal Surgeries

Efficacy of Rectus Sheath Block for Postoperative Pain Management: A Comparison with Epidural Analgesia

Efficacy of Rectus Sheath Block for Postoperative Pain Management: A Comparison with Epidural Analgesia

Efficacy of combined ultrasound guided anterior and posterior rectus sheath block for postoperative analgesia following umbilical hernia repair: Randomized, controlled trial

BackgroundAnatomical variations in the thoracic nerves T7 to T11was found in up to 30% of the population as the anterior cutaneous branch of the nerves are formed before the rectus sheath and so do not penetrate the posterior wall of the rectus sheath. Posterior rectus sheath block was found to be effective for perioperative analgesia. We tested the efficacy of addition of anterior rectus sheath block to capture the anterior cutaneous branch of intercostal nerves as they emerge from the rectus muscle in anterior rectus sheath.MethodSixty-three ASA I/II adult patients listed for elective umbilical hernia repair were randomly allocated in one of three groups: Bupivacaine hydrochloride 0.25% was injected by ultrasound guided bilateral posterior rectus sheath in Group I (PRSB) and bilateral anterior and posterior rectus sheath in Group II (APRSB). Group III received bilateral anterior and posterior rectus sheath block using isotonic saline. Twenty-four hours postopetrative morphine consumption, Intraoperative rescue fentanyl dose, equivalent morphine dose in the recovery unit and first morphine dose were recorded. The quality of analgesia is assessed by Visual Analogue Scale for 24 h.ResultsMean intraoperative rescue fentanyl dose was 19.23 ± 4.96 μg, 15.28 ± 2.75 μg and 12.85 ± 3.65 μg in control, PRSB and APRSB groups respectively (P < 0.001). The mean opioid consumptions in PACU was PRSB 3.47 ± 0.13 mg, APRSB 2.91 ± 0.15 mg and control 4.04 ± 0.56 mg respectively (P < 0.001). Significant difference in intraoperative rescue fentanyl was found between PRSB and APRSB group (P = 0.020). Also statistically significant difference was found between PRSB and APRSB groups in 24 h morphine consumption (P = 0.034).ConclusionAddition of ultrasound anterior rectus sheath block together with posterior rectus sheath block added more significant analgesia than if we perform posterior rectus sheath alone. This was evidenced by decrease in Intraoperative rescue fentanyl, PACU morphine analgesia, 24 h morphine and pain assessment score.