In this video, a bilateral ultrasound-guided rectus sheath nerve block is demonstrated on a 7-year-old male child undergoing umbilical hernia repair. After the induction of general anesthesia, nerve block time-out is conducted. Following this, the periumbilical area is cleansed using chlorhexidine. A high-frequency linear ultrasound probe is then placed in a transverse orientation lateral to the umbilicus to identify the rectus muscle and its posterior rectus sheath. The three lateral abdominal wall muscles—internal oblique, external oblique, and transversus abdominis—are also visualized lateral to the rectus muscle.
Using an in-plane technique, a 22-gauge, 50-millimeter-long Pajunk needle is inserted from lateral to medial direction. The needle is advanced through the subcutaneous tissue and the body of the rectus muscle until it reaches the target plane between the rectus muscle and the posterior rectus sheath. Correct needle placement is confirmed through hydro dissection with normal saline, where proper spread is indicated by separation of the rectus sheath from the muscle or by the rectus muscle lifting up.
Next, 0.2% Ropivacaine, a local anesthetic, is incrementally injected. The procedure is then repeated on the opposite side with total drug volume typically ranging from 0.05 ml/kg to 1.0 ml/kg up to a maximum total volume of 10 to 20 ml. The patient tolerates the procedure well and does not require any opioids intraoperatively or postoperatively in the post-anesthesia care unit.
Ultrasound-guided bilateral rectus sheath nerve block has emerged as a valuable technique in regional anesthesia for various abdominal surgeries requiring midline abdominal periumbilical incisions. This procedure involves the precise placement of local anesthetic between the rectus muscle and its posterior sheath, effectively blocking the anterior cutaneous branches of the lower thoracoabdominal nerves. The technique is performed under ultrasound guidance, ensuring accurate needle placement and confirming proper spread of the anesthetic. Benefits include reduced intraoperative and postoperative opioid requirements, enhanced postoperative pain management, and improved patient outcomes. This abstract summarizes the indications, potential complications, methods and procedural steps associated with ultrasound-guided rectus sheath nerve block, highlighting its efficacy in providing effective analgesia, and facilitating early recovery in abdominal surgery patients.
The ultrasound-guided bilateral rectus sheath nerve block is a straightforward and effective technique utilized to provide analgesia for midline abdominal incisions, particularly those involving the periumbilical region of the abdominal wall.²
Here, we are describing this technique being utilized for a 7-year-old child presenting for umbilical hernia repair following parental consent.
Equipment needed:
- High-frequency linear ultrasound probe
- Sterile ultrasound probe cover
- 50 mm hyperechoic nerve block needle
- Ropivacaine 0.2% or Bupivacaine 0.25%
- 10 mL syringe
- Normal saline syringe for hydro dissection
- Chlora Prep sticks
- Sterile gloves
Procedure:
After induction of general anesthesia, a nerve block time-out is performed to ensure procedural accuracy and patient safety. Following this, the periumbilical area is prepared with chlorhexidine for sterility. Using a high-frequency linear ultrasound probe positioned transversely lateral to the umbilicus, the operator identifies anatomical landmarks such as the rectus muscle and its posterior rectus sheath, as well as the internal oblique, external oblique, and transversus abdominis muscles situated laterally¹.
Using an in-plane technique, a 22-gauge, 50-millimeter-long Pajunk needle is inserted from a lateral to medial direction. The needle is advanced through the layers of subcutaneous tissue and the rectus muscle until it reaches the intended plane between the rectus muscle and its posterior sheath. Confirmation of needle placement is achieved through hydrodissection with normal saline, confirming optimal spread indicated by separation of the rectus sheath or elevation of the rectus muscle.
Following this, 0.2% Ropivacaine is incrementally injected. The procedure is then replicated on the opposite side, adjusting the total drug volume based on patient weight, typically ranging from 0.05 ml/kg to 1.0 ml/kg, with a maximum total volume of 10 to 20 ml.
The peripheral nerve block was successfully completed without any complications. The patient tolerated the procedure well.
The ultrasound-guided bilateral rectus sheath nerve block has become an essential technique in regional anesthesia for providing effective somatic analgesia for midline abdominal incisions, especially periumbilical incisions. The rectus abdominis muscle extends across the anterior abdominal wall from the xyphoid process and costal cartilage to the pubic symphysis, surrounded by the rectus sheath formed by the aponeuroses of the internal oblique, external oblique, and transversus abdominis muscles¹. Intercostal nerves traverse the transversus abdominis plane and enter the rectus sheath at its lateral margin, positioning themselves between the rectus muscle and its posterior sheath. This technique facilitates precise localization and administration of local anesthetic to block the anterior perforating branches of these nerves, effectively managing perioperative pain and minimizing opioid requirements.
Although rare, potential complications may include peritoneal or bowel puncture, as well as injury to the epigastric vessels within the muscle, potentially resulting in hematoma formation within the rectus sheath. The use of ultrasound improves the accuracy and consistency of this block, thereby reducing the likelihood of complications and optimizing outcomes in a variety of midline abdominal surgical procedures².
There are no conflicts to disclose in this case.
None
1. NYSORA. “Tips for a Rectus Sheath Block.” NYSORA, 2 May 2024, www.nysora.com/news/tips-for-a-rectus-sheath-block-3/. Accessed 17 July 2024.
2. NYSORA. “Truncal and Cutaneous Nerve Blocks.” NYSORA, 20 Sept. 2013, www.nysora.com/techniques/truncal-and-cutaneous-blocks/truncal-and-cutaneous-blocks/.
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