|Year : 2017 | Volume
| Issue : 1 | Page : 219-223
The efficacy of rectus sheath block for pain management following laparoscopic orchiopexy surgery
Department of Anaesthesiology, Ain Shams University, Cairo, Egypt
|Date of Web Publication||3-Aug-2018|
Department of Anaesthesiology, Ain Shams University, Cairo, 11772
Source of Support: None, Conflict of Interest: None
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.
Keywords: analgesia, bupivacaine, laparoscopic orchiopexy, pediatric, rectus block
|How to cite this article:|
Shokri H. The efficacy of rectus sheath block for pain management following laparoscopic orchiopexy surgery. Ain-Shams J Anaesthesiol 2017;10:219-23
|How to cite this URL:|
Shokri H. The efficacy of rectus sheath block for pain management following laparoscopic orchiopexy surgery. Ain-Shams J Anaesthesiol [serial online] 2017 [cited 2020 Feb 21];10:219-23. Available from: http://www.asja.eg.net/text.asp?2017/10/1/219/238459
| Introduction|| |
Laparoscopic techniques have been used for the treatment of intra-abdominal testes as an extension of diagnosis. The impetus for development of these techniques was the difficulty in performing successful open orchiopexy for high undescended testicles .
Many techniques have been adopted for laparoscopic orchiopexy, with success rates ranging from 63 to 97% .
Laparoscopic procedures cause considerable pain despite their ‘minimally invasive’ character because of stretching of the abdominal cavity, peritoneal inflammation, and phrenic nerve irritation caused by residual gas . Carbon dioxide insufflation causes more irritation than nitrous oxide; in addition, a trocar has to be inserted through a midline incision to penetrate the rectus sheath and peritoneum . Regional analgesia of the anterior abdominal wall indicates successful blockade of the relevant intercostal nerves within the rectus sheath. It can be an excellent postoperative analgesic technique for a variety of surgical procedures, especially when used as a part of multimodal analgesia .
The rectus sheath block was first described in 1899 and was initially used for abdominal wall muscle relaxation during laparotomy before the addition of neuromuscular block . Now it is used for analgesia after umbilical or incisional hernia repairs and other midline surgical incisions. The rectus sheath block was first applied in pediatric surgery by Ferguson et al. . The authors discussed that the tendinous intersections of the rectus sheath are only anterior and do not extend through the thickness of the muscle, and hence a potential space would exist between the posterior aspect of its sheath.
This potential space would allow dispersion of local anesthetics at several levels, producing an effect on several intercostal nerves. The puncture was performed on each side of the abdomen, just above and lateral to the umbilicus, half to 1 cm medial to the linea semilunaris. The block proved to be safe and effective both for umbilical and for paraumbilical hernia repair .
The aim of this technique is to block the terminal branches of the 9th, 10th, and 11th intercostal nerves, which run between the internal oblique and transversus abdominis muscles to penetrate the posterior wall of the rectus abdominis muscle (RM) and end in an anterior cutaneous branch supplying the skin of the umbilical area.
In recent years, high-frequency ultrasonography is of increasing interest in regional anesthesia, as direct visualization of the anatomic structures allows optimal placement of the needle and thereby reduces the risk of inadvertent interneural, intravascular, or adjacent structural injury (peritoneum). Injection into the peritoneal cavity will lead to failure of the block .
The aim of the study was to evaluate the efficacy of rectus sheath block for pain management following laparoscopic orchiopexy surgery.
| Patients and methods|| |
After obtaining approval from the medical ethical committee of Ain Shams University, Egypt, informed consent from the parents was obtained in all cases. Fifty children, aged 1–6 years, of American Society of Anesthesiologists physical status I or II, scheduled for laparoscopic orchiopexy, were included in this study, which was conducted in 2014–2015. Children with a history of convulsions, neuromuscular disease, or hematological disorders were excluded.
No premedication was given. Intraoperative monitoring included ECG, pulse oximetry, noninvasive blood pressure monitoring, and end tidal carbon dioxide concentration.
Patients were allocated randomly by a computer-generated list into two groups: the ultrasound (U/S)-guided rectus sheath block (REC) group (25 patients), which received a single injection of plain bupivacaine 0.25% (0.4 ml/kg) on each side under real-time U/S control, and the general anesthesia-only group (GA) group (25 patients), in which no rectus sheath block was performed.
After general anesthesia was induced and venous access established, fentanyl 2 mg/kg was administered and an appropriately sized endotracheal tube was placed. Intubation was facilitated by atracurium (0.5 mg/kg). All patients were mechanically ventilated with pressure-controlled mode with targeted EtCO2 (30–35 mmHg) and anesthesia was maintained with 1 minimum alveolar concentration isoflurane in a mixture of 50% air and oxygen in all patients throughout the procedure.
In the REC group, the 5–16 MHz US linear probe (Sonosite M TURBO; FUJIFILM SonoSite Inc., USA) was positioned 1 cm above the umbilicus. Adjustments in depth were made in order to achieve the optimal sonographic view of both RMs, their sheaths, and adjacent structures.
The sheath and lateral edge of the RM were identified; the peritoneum and the aponeurosis of the ipsilateral transverse abdominis, internal and external oblique muscles were localized. After aseptic preparation of the puncture site, the U/S probe was covered with sterile U/S gel (Ultra/Phonic; Pharmaceutical Innovations Inc., Newark, New Jersey, USA). The block was performed using a facet tip needle (Stimuplex A insulated needle 22 G 50 mm). The needle was introduced so that its long axis was parallel to the U/S probe ignorer to reach the lateral border of the rectus muscle, and proceeded slowly and carefully until the tip of the needle was seen between the posterior aspect of the rectus abdominis and its sheath. A single injection of plain bupivacaine 0.25% (0.4 ml/kg) was injected on each side under real-time U/S control.
Surgery was then performed and hemodynamic parameters were recorded. Additional doses of fentanyl at 1 mg/kg were administered if there was an increase in the heart rate or blood pressure by more than 10% following the skin incision or during the procedure.
At the end of the procedure, muscle relaxation was reversed with neostigmine 50 µg/kg and atropine sulfate 15 µg/kg. Then the endotracheal tube was removed and general anesthesia was discontinued. Children were transferred to the postanesthesia care unit (PACU). Postoperative analgesia was evaluated by a blinded investigator using the modified CHEOPS (the Children’s Hospital of Eastern Ontario Pain Scale)  in the PACU, and then at 3, 6, 12, 18, and 24 h. CHEOPS is an observational scale for measuring postoperative pain in children aged 1–6 years. The scale includes six categories of pain behavior: cry, facial, verbal, torso, touch, and legs. A score ranging from 0 to 2 or 1 to 3 is assigned to each activity and the total score ranges between 4 and 13. Children who scored 5 or more at any of the evaluated times were to be administered morphine 0.1 mg/kg intravenously.
Primary outcome measure
The primary outcome measure was the total dose of analgesic required.
Secondary outcomes measures
These included pain scores, the duration of hospitalization, and postoperative complications such as respiratory depression, which is defined as respiratory rate less than 10 beats/min, or vomiting.
Ondansetron 0.1 mg/kg was used for patients experiencing vomiting.
Sample size determination
A sample size of 24 patients per group was determined to achieve 80% power to detect a difference of 50% in analgesic requirements at the first 24 h postoperatively between the two groups, with a significance level (α) of 0.05 using a two-sided two-sample t-test; 25 patients per group were included to replace any dropouts.
All statistical calculations were performed using the statistical package for the social sciences (version 17.0; SPSS Inc., Chicago, Illinois, USA) with type I error of 5% and type II error of 10% and power of 80%.
The data were presented as mean±SD or median. Statistical analysis was performed using the independent-sample t-test for determining intergroup comparisons. Quantitative data were compared using the independent t-test. The χ2-test was used for comparison of qualitative data. P values less than 0.05 were considered significant.
| Results|| |
Age, sex, and American Society of Anesthesiologists scores were not statistically different between the two groups (P>0.05). Length of surgery was similar in the groups (P>0.05) ([Table 1]).
The CHEOPS score was significantly lower in the REC group compared with the GA group during the first 3 h postoperatively (P<0.05) ([Table 2]).
|Table 2 Comparison of Children’s Hospital of Eastern Ontario Pain Scale scores in the study groups|
Click here to view
Pain scores 3 h postoperatively did not differ between the two groups.
Postoperative morphine consumption in the REC group was significantly lower than that in the GA group.
Hospital stay was significantly shorter in the REC group compared with the GA group (P<0.001).
The incidence of postoperative vomiting and respiratory depression showed no significant difference between the REC group and the GA group. There was no statistically significant difference in the percentage of oxygen saturation between the groups in the postanesthesia care unit (PACU) ([Table 3]).
|Table 3 Comparison of morphine consumption, oxygen saturation, hospital stay, and incidence of complications in the study groups|
Click here to view
Systolic blood pressure was significantly lower in the REC group compared with the GA group during the first 3 h postoperatively. There was no significant difference between the study groups at other time points ([Table 4]).
Diastolic blood pressure was significantly lower in the REC group compared with the GA group during first 3 h postoperatively, but there was no significant difference between the study groups at other time points ([Table 5]).
| Discussion|| |
The rectus sheath block has been found to be beneficial in providing analgesia in patients undergoing laparoscopic surgery .
The concept of multimodal analgesia has gained popularity in the management of perioperative pain. It includes the use of different modalities of analgesia to provide superior pain relief with reduced analgesic-related side effects . U/S-guided regional analgesia techniques are now widely used to provide multimodal strategies .
This study showed that rectus sheath block with general anesthesia provides more perfect analgesia than general anesthesia alone. Patients of the rectus sheath group had lower pain scores with less morphine utilization postoperatively and shorter hospital stay.
Smith et al.  demonstrated that infiltration by local anesthetic in the middle of the rectus muscle, both above and below the anterior wall of the sheath, would result in more spread around the anterior cutaneous branches whatever the anatomical variation.
In a study by Kamei et al. , patients undergoing single incision laparoscopic cholecystectomy received bilateral rectus sheath block and had significantly lower visual analog scale scores at 2 and 6 h after operation.
A study by James and colleagues showed that children in the bilateral REC group undergoing laparoscopic appendectomy reported significantly lower pain scores compared with controls in the first 3 h after surgery (estimated mean: 2.22 vs. 3.94; effect size: −1.80) (P=0.008). Pain scores after 3 h did not differ between the groups. The groups did not differ in opiate requirements, length of hospital stay, or recovery after discharge .
In a study by Azemati et al.  that included female patients scheduled for elective diagnostic gynecological laparoscopy the group receiving bilateral rectus sheath block had significantly lower visual analog scale scores at 6 h (P<0.001) and 10 h (P<0.004) after laparoscopy when compared with the group receiving intraperitoneal or intraincisional bupivacaine.
In the study by Ozcengiz et al.  of children (1–15 years) undergoing laparotomy by means of a transverse incision, CHEOPS pain scores and sedation scores showed no significant difference between the REC group and the group receiving tramadol intravenously; however, the incidence of postoperative nausea and vomiting and postoperative analgesic consumption were significantly lower in the REC group.
Isaac et al.  showed that postoperative pain scores and postoperative morphine consumption were not significantly different between children undergoing repair of umbilical hernia with rectus sheath block compared with those subjected to surgical wound infiltration of a local anesthetic.
| Conclusion|| |
U/S-guided rectus sheath block is a simple technique to learn. In children undergoing acute laparoscopic orchiopexy, a rectus sheath block combined with general anesthesia was found to be effective in reducing early postoperative pain and opioid consumption compared with general anesthesia alone.
The author thank her colleagues in the Anesthesia Department of Ain Shams University.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Docimo SG. The results of surgical therapy for cryptorchidism: a literature review and analysis. J Urol 1995; 154:1148–1152.
Baker LA, Docimo SG, Surer I, Peters C, Cisek L, Diamond DA, et al.
.. A multi-institutional analysis of laparoscopic orchidopexy. BJU Int 2001; 87:484–489.
Jackson SA, Laurence AH, Hill JC. Does post laparoscopy pain related to residual carbon dioxide? Anesthesia 1996; 51:485–487.
Yarwood J, Berrill A. Nerve blocks of the anterior abdominal wall. Contin Educ Anaesth Crit Care Pain 2010; 10:182–186.
Willschke H, Bosenberg A, Marhofer P, Jahnson S, Kettner SC, Wanzel O, S.Kapral. et al.
.. Ultrasonography-guided rectus sheath block in paediatric anaesthesia − a new approach to an old technique. Br J Anaesth 2006; 97:244–249.
Ferguson S, Thomas V, Lewis I. The rectus sheath block in paediatric anaesthesia: new indications for an old technique? Paediatr Anaesth 1996; 6:463–466.
Abdull Hamid S, Khalil N, Al Motaq N. Ultrasound-guided rectus sheath block in children with umbilical hernia: case series. Saudi J Anaesth 2013; 7:432–435.
Hesselgard K, Larsson S, Romner B. Validity and reliability of the behavioural observational pain scale for postoperative pain measurement in children 1–7 years of age. Pediatr Crit Care Med 2007; 8:102–108.
Smith BE, Suchak M, Siggins D, Challands J. Rectus sheath block for diagnostic laparoscopy. Anaesthesia 1988; 43:947–948.
Joshi GP. Multimodal analgesia techniques and postoperative rehabilitation. Anesthesiol Clin North America 2005; 23:185–202.
Cowlishaw PJ, Scott DM, Barrington MJ. The role of regional anaesthesia techniques in the management of acute pain. Anaesth Intensive Care 2012; 40:33–45.
Kamei H, Ishibashi N, Nakayama G, Hamada N, Ogata Y, Akagi Y. Ultrasound-guided rectus sheath block for single-incision laparoscopic cholecystectomy. Asian J Endosc Surg 2015; 8148–8152
Hamill JK, Liley A, Hill AG. Rectus sheath block for laparoscopic appendicectomy: a randomized clinical trial. ANZ J Surg 2015; 85:951–956.
Azemati S, Khosravi MB. An assessment of the value of rectus sheath block for postlaparoscopic pain in gynecologic surgery. J Minim Invasive Gynecol 2005; 12:12–15.
Ozcengiz D, Bayrak BT, Gulec E, Alkan M. Rectus sheath block for postoperative pain relief in children undergoing major abdominal surgery. J Anesth Clin Sci 2012; 1:5, http://dx.doi.org/10.7243/2049-9752-1-5
Isaac LA, Mc Ewen J, Hayes JA, Crawford MW. A pilot study of rectus sheath block for pain control after umbilical hernia. Pediatr Anesth 2006; 16:406–409.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]