Ultrasound-guided rectus sheath block in children with umbilical hernia: Case series

Abstract

Background:Umbilical hernia repair, a common day-case surgery procedure in children, is associated with a significant postoperative pain. The most popular peripheral nerve blocks used in umbilical hernia repair are rectus sheath infiltration and caudal block. The rectus sheath block may offer improved pain relief following umbilical hernia repair with no undesired effects such as lower limb motor weakness or urinary retention seen with caudal block which might delay discharge from the hospital. Ultrasound guidance of peripheral nerve blocks has reduced the number of complications and improved the quality of blocks. The aim of this case series is to assess the post rectus sheath block pain relief in pediatric patients coming for umbilical surgery.Methods:Twenty two (22) children (age range: 1.5-8 years) scheduled for umbilical hernia repair were included in the study. Following the induction of general anesthesia, the ultrasonographic anatomy of the umbilical region was studied with a 5-16 MHz 50 mm linear probe. An ultrasound-guided posterior rectus sheath block of both rectus abdominis muscles (RMs) was performed (total of 44 punctures). An in-plain technique using Stimuplex A insulated facet tip needle 22G 50mm. Surgical conditions, intraoperative hemodynamic parameters, and postoperative analgesia by means of the modified CHEOPS scale were evaluated.Results:ultrasonograghic visualization of the posterior sheath was possible in all patients. The ultrasound guided rectus sheath blockade provided sufficient analgesia in all children with no need for additional analgesia except for one patient who postoperatively required morphine 0.1 mg/kg intravenously. There were no complications.Conclusions:Ultrasound guidance enables performances of an effective rectus sheath block for umbilical hernia. Use of the Stimuplex A insulated facet tip needle 22G 50mm provides easy, less traumatic skin and rectus muscle penetration and satisfactory needle visualiza.

Evidence for the Use of Ultrasound Imaging in Pediatric Regional Anesthesia

“…There were 23 and 13 articles reporting quality and outcomes of ultrasound imaging for the pediatric population in peripheral and neuraxial blockade, respectively ( Table 2). From the peripheral nerve block (PNB) set, there were 10 RCTs, 4-13 6 prospective observational studies, [14][15][16][17][18][19] 2 retrospective studies, 20,21 and 5 case series [22][23][24][25][26] (Fig. 2).…”

“…A case series of children receiving rectus sheath block for umbilical hernia repair also supports a limited need for postoperative opioid consumption-only one of the 22 children required morphine in the postanesthesia care unit (PACU). 26 Multiple RCTs comparing the use of ultrasound-guided PNBs with local anesthetic wound infiltration reported decreased postoperative analgesic consumption after hernia repair in those who received an ultrasound-guided block. 12,13 One of these RCTs reported that children receiving an ultrasound-guided bilateral rectus sheath block for umbilical hernia repair required fewer doses of both opioid and nonopioid medications in PACU when compared with local anesthetic infiltration as a pain control measure.…”

“…19 Ponde et al, 23 Van Geffen et al 25 Trunk: Alsaeed et al, 26 Boretsky et al, 21 Ford et al, 15 Hong et al, 16 4 Ponde and Diwan 10…”

“…Ultrasound imaging allows for accurate identification of nerves as well as important anatomical structures 15,19,25,26 and can aid in the placement of the needle/catheter. 21,25 Three studies 21,23,24 reported being able to visualize the needle tip in all patients, and 1 study 23 reported visualization of the catheter tip in 73% of sciatic perineural catheter placements in children listed for congenital talipoequinovarus surgery.…”

Essentials of Our Current Understanding

“…It has been widely studied in umbilical hernia repair where data from case series indicate that it provides effective analgesia 36,167,177 and may even be used for primary surgical anesthesia [178][179][180] in selected adult patients. However, it is controversial as to whether it offers significant analgesic benefit over simple surgical wound infiltration.…”