Ultrasound-Guided Rectus Sheath Block for Intraoperative and Postoperative Pain Management in Pediatric Patients

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.