Printer Friendly

The ultrasound-guided rectus sheath block as an anaesthetic in adult paraumbilical hernia repair.

Rectus sheath block was first described by Schleich in 1899 as a means of providing anterior abdominal wall relaxation in adults (1). In more recent times, its use has been more common in paediatric patients (2,3). Its use in abdominal gynaecological procedures and umbilical hernia repair has also been described (4,5). We describe its use as a sole anaesthetic agent in the mesh repair of a paraumbilical hernia in an elderly patient with significant co-morbidities.

The patient was a wheelchair bound, 83-year-old woman with multiple co-morbidities including Type 2 diabetes (complicated by diabetic nephropathy), hypertension, hyperlipidaemia and ischaemic cardiomyopathy. She had been hospitalised several times for pulmonary oedema. Her most recent echocardiographic examination demonstrated a left ventricular ejection fraction of 15% and segmental wall motion abnormalities at rest. In addition, she had documented cervical myelopathy for which she had been treated conservatively. She presented with small bowel obstruction which was attributed to a small paraumbilical hernia and a mesh repair was planned accordingly.

We elected to perform the surgery under a bilateral rectus sheath block with judicious sedation in an effort to minimise haemodynamic instability. She was sedated with a very small dose of intravenous ketamine (10 mg) and midazolam (0.5 mg) prior to the blocks, which were well tolerated. The rectus sheath block was performed with real-time ultrasound guidance (38 mm broadband linear array, Sonosite Micromaxx[TM], SonoSite Inc., Bothell WA, USA). A simple 23 G hypodermic needle was used in a cross-sectional, out-of-plane approach to the rectus sheath. Ten ml of 0.5% bupivacaine and 5 ml of 1% lignocaine (with adrenaline) were then deposited in the potential space between the rectus abdominis muscle and the posterior rectus sheath (Figure 1).

Surgery was commenced and a low-dose propofol infusion was started for further sedation. A small dose of intravenous fentanyl (25 [micro]g), midazolam (0.5 mg) and ketamine (10 mg) was required during surgical reduction of the hernia due to bowel manipulation. The surgical incision was not large and no further analgesics were needed during the 90 minute surgery. The patient remained haemodynamically stable throughout the surgery, all variables remaining within 15% of baseline. She was monitored in the post-anaesthetic care unit after surgery and discharged to the ward within an hour without requiring any further analgesics.


The rectus sheath block anaesthetises the 9th, 10th and 11th intercostal nerves in its course through the rectus sheath. This provides somatic anaesthesia to the abdomen, sufficient for umbilical surgery or minor surgery in its immediate vicinity. Avoiding the physiological sympathectomy associated with central neuraxial blockade minimises the haemodynamic fluctuations associated with such blocks. Even incisions in the suprapubic region may derive some analgesic benefit, especially if supplemented with ilioinguinal blocks (4).

Ultrasonography provides non-invasive real-time imaging of the anatomy for rectus sheath blocks. This may, logically, increase the success rate and reduce the incidence of inadvertent needle entry into the peritoneum, vascular or bowel injury.

We believe that this often-overlooked block remains a useful tool in modern day practice. While the risks of bowel and vessel injury have to be acknowledged, these are greatly reduced by the accurate placement of the needle under direct, real-time ultrasonography.

With ultrasound imaging becoming increasingly available in anaesthetic practice, the rectus sheath block could play a more prominent role in the provision of anaesthesia and analgesia in selected patients.


(1.) Schleich CL. Schmerzlose Operationen. Fourth ed. J. Springer 1899; p. 240.

(2.) Ferguson S, Thomas V, Lewis I. The rectus sheath block in paediatric anaesthesia: new indications for an old technique? Paediatr Anaesth 1997; 6:463-466.

(3.) Willschke H, Bosenberg A, Marhofer P, Johnston S, Kettner SC, Wanzel O et al. Ultrasonography-guided rectus sheath block in paediatric anaesthesia--a new approach to an old technique. Br J Anaesth 2006; 97:244-249.

(4.) Yentis SM, Hills-Wright P, Potparic O. Development and evaluation of combined rectus sheath and ilioinguinal blocks for abdominal gynaecological surgery. Anaesthesia 2000; 54:475-479.

(5.) Muir J, Ferguson S. The rectus sheath block--well worth remembering. Anaesthesia 1996; 51: 893-894.




Changi General Hospital, Singapore
COPYRIGHT 2009 Australian Society of Anaesthetists
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2009 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:Correspondence
Author:Phua, D.S.K.; Phoo, J.W.H.; Koay, C.K.
Publication:Anaesthesia and Intensive Care
Article Type:Report
Geographic Code:9SING
Date:May 1, 2009
Previous Article:Risk factors and outcomes of methicillin-resistant Staphylococcus aureus bacteraemia in critically ill patients: a case control study.
Next Article:Contained neck emphysema: an enigma?

Related Articles
A salient rectus abdominis hematoma due to enoxaparin/Enoksaparine bagli rektus abdominis hematomu.
Rectus sheath hematoma due to cough attacks in an elderly patient on oral anticoagulant therapy/Oral antikoagulan kullanan yasli bir hastada oksuruk...
A prospective randomised controlled trial of ultrasound guided versus nerve stimulation guided distal sciatic nerve block at the popliteal fossa.
The serendipitous origin of ultrasound-guided regional anaesthesia.
Ultrasound-guided transversus abdominis plane block for neonatal abdominal surgery.
Application of the transversus abdominis plane block in the intensive care unit.
Iliac crest bone graft--could this be an ideal indication for a transversus abdominus plane block?

Terms of use | Privacy policy | Copyright © 2021 Farlex, Inc. | Feedback | For webmasters |