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Abdominal wall blocks: Difference between revisions
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== ILIOINGUINAL/ILIOHYPOGASTRIC NERVE BLOCK (ILNB) == | == ILIOINGUINAL/ILIOHYPOGASTRIC NERVE BLOCK (ILNB) == | ||
The ilioinguinal/iliohypogastric nerve block (ILNB) provides excellent analgesia after inguinal hernia repair, hydrocele repair and orchidopexy. It does not abolish visceral pain due to peritoneal traction or manipulation of the spermatic cord during inguinal hernia repair or orchidopexy. Bilateral blocks can be used, but it is important to keep the dose of local anaesthetic within safe limits. Perform ILNBs after induction of anaesthesia, before the start of surgery; it is important to make sure that the child is adequately anaesthetised when the cord structures are mobilised, and that additional local infiltration/analgesia is used if a scrotal incision is made. There is much anatomical variation of nerve position between the abdominal wall muscles. The effectiveness of this block can be improved greatly when performed with ultrasound, and lower amounts of local anaesthetic can be used.<ref>van Schoor AN, Boon JM, Bosenberg AT, Abrahams PH, Meiring JH. Anatomical considerations of the pediatric ilioinguinal/ iliohypogastric nerve block. Paediatr Anaesth. 2005; 15: 371- 377.</ref> Anatomy (see Figure 1): | The ilioinguinal/iliohypogastric nerve block (ILNB) provides excellent analgesia after inguinal hernia repair, hydrocele repair and orchidopexy. It does not abolish visceral pain due to peritoneal traction or manipulation of the spermatic cord during inguinal hernia repair or orchidopexy. Bilateral blocks can be used, but it is important to keep the dose of local anaesthetic within safe limits. Perform ILNBs after induction of anaesthesia, before the start of surgery; it is important to make sure that the child is adequately anaesthetised when the cord structures are mobilised, and that additional local infiltration/analgesia is used if a scrotal incision is made. There is much anatomical variation of nerve position between the abdominal wall muscles. The effectiveness of this block can be improved greatly when performed with ultrasound, and lower amounts of local anaesthetic can be used.<ref>van Schoor AN, Boon JM, Bosenberg AT, Abrahams PH, Meiring JH. Anatomical considerations of the pediatric ilioinguinal/ iliohypogastric nerve block. Paediatr Anaesth. 2005; 15: 371- 377.</ref> Anatomy (see Figure 1): | ||
[[index.php%3Ftitle=File:Anatomy_of_the_ilioinguinal-iliohypogastric_nerve_block.jpg|alt=|thumb|'''Figure 1'''. Anatomy of the ilioinguinal/iliohypogastric nerve block]] | |||
* The iliohypogastric (T12, L1) and ilioinguinal (L1) nerves are terminal branches of the lumbar plexus. They lie deep to the internal oblique. | * The iliohypogastric (T12, L1) and ilioinguinal (L1) nerves are terminal branches of the lumbar plexus. They lie deep to the internal oblique. | ||
* The iliohypogastric nerve supplies the gluteal region and the skin over the pubic symphysis. | * The iliohypogastric nerve supplies the gluteal region and the skin over the pubic symphysis. | ||
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* In infants the average nerve-peritoneum distance is only 3.3mm<ref>Willschke H, Marhofer P, Bosenberg A et al. Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children. Br J Anaesth. 2005; 95: 226-230.</ref> . | * In infants the average nerve-peritoneum distance is only 3.3mm<ref>Willschke H, Marhofer P, Bosenberg A et al. Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children. Br J Anaesth. 2005; 95: 226-230.</ref> . | ||
* The fascial plane between the transversus abdominis muscle and the transversalis fascia is in continuity with the space around the femoral nerve. | * The fascial plane between the transversus abdominis muscle and the transversalis fascia is in continuity with the space around the femoral nerve. | ||
=== Dose === | === Dose === | ||
Use a volume of up to 0.5ml.kg-1 0.25% bupivacaine for the landmark technique. In expert hands as little as 0.075 ml.kg-1 0.25% bupivacaine can be effective using ultrasoundguidance; <ref name=":0">Willschke H, Bosenberg A, Marhofer P et al. Ultrasonographicguided ilioinguinal/iliohypogastric nerve block in pediatric anesthesia: what is the optimal volume? Anesth Analg. 2006; 102: 1680-1684.</ref> we recommend 0.1-0.2ml.kg-1. | Use a volume of up to 0.5ml.kg-1 0.25% bupivacaine for the landmark technique. In expert hands as little as 0.075 ml.kg-1 0.25% bupivacaine can be effective using ultrasoundguidance; <ref name=":0">Willschke H, Bosenberg A, Marhofer P et al. Ultrasonographicguided ilioinguinal/iliohypogastric nerve block in pediatric anesthesia: what is the optimal volume? Anesth Analg. 2006; 102: 1680-1684.</ref> we recommend 0.1-0.2ml.kg-1. | ||