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16 - Ultrasound-guided rectus sheath block

from Section 4 - Truncal blocks

Published online by Cambridge University Press:  05 September 2015

Harshad Gurnaney
Affiliation:
University of Pennsylvania, Philadelphia, PA, USA
Arjunan Ganesh
Affiliation:
University of Pennsylvania, Philadelphia, PA, USA
Stephen Mannion
Affiliation:
University College Cork
Gabrielle Iohom
Affiliation:
University College Cork
Christophe Dadure
Affiliation:
Hôpital Lapeyronie, Montpellier
Mark D. Reisbig
Affiliation:
Creighton University Medical Center, Omaha, Nebraska
Arjunan Ganesh
Affiliation:
Children’s Hospital of Philadelphia
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Summary

Clinical use

The rectus sheath block can be used to provide post-operative analgesia for anterior abdominal procedures (Gurnaney et al., 2011). In 1996 the rectus sheath block was suggested as an option for providing post-operative analgesia for an umbilical hernia repair (Ferguson et al., 1996). Since then this technique has been used to provide analgesia for umbilical and epigastric hernia repair, laparoscopic surgery, and other small midline incisions and has been found to provide better analgesia than wound infiltration (Breschan et al., 2013; Dingeman et al., 2013; Flack et al., 2014). It has also been used for the relief of chronic abdominal wall pain (Skinner and Lauder, 2007). A rectus sheath catheter technique can be used for midline laparotomy procedures for providing post-operative analgesia (Courreges and Poddevin, 1998).

The rectus sheath block anesthetizes the anterior divisions of the seventh, eighth, ninth, tenth, and eleventh thoracic intercostal nerves, which are called the thoracoabdominal nerves. These nerves innervate the anterior abdominal wall. They continue anteriorly from the intercostal space into the abdominal wall. In the abdominal wall the nerves reach the posterior layer of the internal oblique aponeurosis and continue between the transversus abdominis and internal oblique muscles. At the lateral border of the rectus abdominis muscle, the external oblique aponeurosis and the anterior lamella of the internal oblique apo-neurosis form the anterior rectus sheath, while the posterior lamella of the internal oblique aponeurosis and the aponeurosis of the transversus abdominis form the posterior rectus sheath. At the lateral edge of the rectus abdominis muscle each nerve pierces the internal oblique aponeurosis and lies between the rectus abdominis muscle and the posterior rectus sheath. These nerves supply the rectus abdominis and end as the anterior cutaneous branch of the abdomen. The ninth thoracic nerve supplies the skin above the umbilicus, the tenth nerve supplies the umbilical region, and the eleventh nerve supplies the skin below the umbilicus.

This region is readily visualized using ultrasound, allowing accurate deposition of local anesthetic (LA) into the rectus sheath itself (Flack et al., 2014). No correlation has been found between the depth of the posterior rectus sheath and the child's weight, height, or body surface area (Willschke et al., 2006).

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Publisher: Cambridge University Press
Print publication year: 2015

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References

Breschan, C, Jost, R, Stettner, H, et al. (2013) Ultrasound-guided rectus sheath block for pyloromyotomy in infants: a retrospective analysis of a case series. Paediatr Anaesth. 23,1199–204.Google Scholar
Courreges, P, Poddevin, F. (1998) Rectus sheath block in infants: what suitability? Paediatr Anaesth. 8,181–2.Google Scholar
Dingeman, RS, Barus, LM, Chung, HK, et al. (2013) Ultrasonography-guided bilateral rectus sheath block vs. local anesthetic infiltration after pediatric umbilical hernia repair: a prospective randomized clinical trial. JAMA Surg. 148,707–13.Google Scholar
Dolan, J, Smith, M. (2009) Visualization of bowel adherent to the peritoneum before rectus sheath block: another indication for the use of ultrasound in regional anesthesia. Reg Anesth Pain Med. 34,280–1.Google Scholar
Ferguson, S, Thomas, V, Lewis, I. (1996) The rectus sheath block in paediatric anaesthesia: new indications for an old technique? Paediatr Anaesth. 6,463–6.Google Scholar
Flack, SH, Martin, LD, Walker, BJ, et al. (2014) Ultrasound-guided rectus sheath block or wound infiltration in children: a randomized blinded study of analgesia and bupivacaine absorption. Paediatr Anaesth. 24,968–73.Google Scholar
Gurnaney, HG, Maxwell, LG, Kraemer, FW, et al. (2011) Prospective randomized observer-blinded study comparing the analgesic efficacy of ultrasound-guided rectus sheath block and local anaesthetic infiltration for umbilical hernia repair. Br J Anaesth. 107,790–5.Google Scholar
Skinner, AV, Lauder, GR. (2007) Rectus sheath block: successful use in the chronic pain management of pediatric abdominal wall pain. Paediatr Anaesth. 17,1203–11.Google Scholar
Willschke, H, Bösenberg, A, Marhofer, P, et al. (2006) Ultrasonography-guided rectus sheath block in paediatric anaesthesia-a new approach to an old technique. Br J Anaesth. 97,244–9.Google Scholar
Yuen, PM, Ng, PS. (2004) Retroperitoneal hematoma after a rectus sheath block. J Am Assoc Gynecol Laparosc. 11,448.Google Scholar

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