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.

Keywords: Anesthesia; analgesia; anesthetic techniques; peripheral nerve block; postoperative; rectus sheath block; regional; surgery; ultrasonography; umbilical; umbilical hernia.

Figure 1

Short-axis sonographic view of the periumibilical region shows: the rectus muscle surrounded by the rectus sheath (RS), internal oblique muscle (I.O), external oblique muscle (E.O), transversus abdominis muscle (T.A)

Figure 2

Needle tip and shaft visualization within the posterior rectus sheath fascial split by ultrasound during rectus sheath block and injection of local anesthesia, the rectus sheath (RS), internal oblique muscle (I.O), external oblique muscle (E.O), transversus abdominis muscle (T.A), local anesthesia (LA)

Figure 3

Needle position; in plane technique, the block needle is lateral to the ultrasound probe