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26923 Regional Blocks for Postoperative Pain Control
Fig. 23.6 Ultrasound probe position for transversus ab-
dominis plane block
Step-by-Step Technique
Place the probe in a transverse plane with the medial end of probe over the umbilicus and obtain
an image of the rectus abdominis muscle. Slide
the probe laterally across the abdominal wall with
the goal to have the probe in the anterior axillary
line, between the costal margin and iliac crest,
until three muscle layers are present (Fig. 23.6).
The most superficial one is the external oblique
followed by the internal oblique and the transversus abdominis muscle. Continue to move the
probe laterally until the transversus abdominis
muscle terminates on the screen (Fig. 23.7). The
site of injection is between the internal oblique
and transversus abdominis muscles, close to the
termination of transversus abdominis muscle.
The needle is advanced from anterior to poste-
Fig. 23.8 Medial to lateral needle orientation for trans-
verses abdominis and quadratus lumborum plane blocks
rior direction through adipose tissue, external,
and internal oblique muscles (Fig. 23.8). Correct
needle position within the TAP is confirmed by
real-time ultrasound visualization of saline hydrodissecting the plane between the two muscle
layers (Fig. 23.9). Once proper needle location is
confirmed local anesthetic is injected.
Alternate Techniques
To obtain analgesia above the umbilicus, a subcostal TAP block is necessary. The probe should
be placed parallel to the costal margin and
Fig. 23.7 Ultrasound anatomy of transversus abdominis
plane block: 1 adipose tissue; 2 external oblique muscle; 3
internal oblique muscle; 4 transversus abdominis muscle
Fig. 23.9 Local anesthetic hydrodissecting transversus
abdominis plane in a neonate: 1 external oblique muscle;
2 internal oblique muscle; 3 transversus abdominis muscle; 4 needle
270 M. Visoiu
Fig. 23.10 Ultrasound probe position for subcostal trans-
versus abdominis plane block
move medially just inferior to the costal margin
(Fig. 23.10). Transversus abdominis muscle can
be seen extending behind the rectus abdominis
muscle (Fig. 23.11). The needle should be inserted in a medial to lateral direction beneath the
costal margin (Fig. 23.12) and the medication
should be seen hydrodissecting the plane above
the transversus abdominis muscle.
In order to reach as many dermatomes as possible, a quadratus lumborum block can be performed. A lateral position with the operative side
up (Fig. 23.13) or “sloppy lateral” (positioned
supine with the body rotated towards the opposite side to have access to the patient’s back at
the block site) (Fig. 23.1). The probe should be
placed between the costal margin and iliac crest
and moved as posterior as possible until quadratus lumborum muscle is identified (Fig. 23.14).
Fig. 23.12 Medial to lateral needle orientation for sub-
costal transversus abdominis plane block
Fig. 23.13 Patient position for posterior and quadratus
lumborum transversus abdominis plane block
Fig. 23.11 Ultrasound anatomy of subcostal transver-
sus abdominis plane blocks: 1 adipose tissue; 2 external
oblique muscle; 3 internal oblique muscle; 4 transversus
abdominis muscle; 5 rectus muscle
Fig. 23.14 Ultrasound anatomy of quadratus lumbo-
rum block: 1 adipose tissue; 2 external oblique muscle;
3 internal oblique muscle; 4 transversus abdominis muscle; 5 quadratus lumborum muscle; 6 latissimus dorsi
muscle
27123 Regional Blocks for Postoperative Pain Control
Fig. 23.15 Needle position under the anterior border of
quadratus lumborum muscle: 1 needle; 2 transversus abdominis muscle; 3 quadratus lumborum muscle; 4 local
anesthetic
The needle is inserted in a medial to lateral direction beneath the anterior border of quadratus
lumborum muscle (Fig. 23.15). This block may
be very challenging because the muscle is not
always easy to identify and is difficult to keep
the needle in the correct tissue plane as the body
curves laterally.
Medication 0.25 ml/kg of local anesthetic,
for a maximum of 0.5 ml/kg/per site can be
injected.
Complications Skin bruises, hematoma, intravascular and intraperitoneal injection, perforation of liver, abdominal perforations, femoral
block.
RS Nerve Blocks
Introduction The RS blocks are effective for
midline abdominal incisions. This procedure
aims to block the terminal branches of the 9th,
10th, and 11th intercostal nerves within the posterior RS. The ultrasound use improves successful placement of local anesthesia.
Anatomy The RS is formed by aponeurosis
of the transversus abdominis, the external and
internal oblique muscles. There is a variation of
these layers from the xyphoid to the symphysis
pubis. It contains the rectus abdominis muscles
that run vertically next to the midline from the
lower anterior ribs to the pubis. The RS consists
of two compartments: the anterior and posterior
RSs. Beneath the posterior RS lie the transversalis fascia, peritoneum, and abdominal content.
Indications
hernia repair, ileocecetomy with small mid
line incisions, pyloromiotomy, laparoscopic
and robotic surgeries such as cholecystectomy,
appendectomy, nephrectomy, oophorectomy,
Nissen procedure, and gastric tube placement to
provide analgesia at umbilicus instrument site.
Ultrasound Technique
Ultrasound Probe High-frequency linear probe
(15/13−6 MHz), small footprint for patients
than 20−30
Umbilical, epigastric, and ventral
-
In-plane.
less
kg.
Scientific Literature in Children Long et al.
showed that overall complications associated
with TAP blocks in children are very low (0.3 %)
[6].
Important Points TAP blocks do not cover the
peritoneal or visceral pain. A posterior ultrasound
TAP approach and injection under the anterior
border of quadratus lumborum muscle results in
a posterior spread of local anesthetic with longer
duration of analgesia [25, 26].
Patient Position Supine.
Step-by-Step Technique
The transducer is positioned just lateral to the
umbilicus and moved laterally a few centimeters until the lateral border of the rectus muscle
is visualized (Fig. 23.16). Moving more laterally, the muscle is seen as a narrow white band
of tissue and the transversus abdominis muscle
appears. Move the probe back, the optimal site
for injection is at the lateral border of the rectus
muscle (Fig. 23.17). Deep to the muscle, identify
272 M. Visoiu
Fig. 23.16 Ultrasound probe position for rectus sheath
block
the bright white (hyperechoic) layer of fascia. An
echogenic needle is advanced from lateral to medial direction, through the adipose tissue under
the muscle (Fig. 23.18). A few milliliters (ml)
of saline solution are injected until the spread of
medication is visualized in the correct location,
deep to the rectus muscle, superficial to the posterior aspect of the RS, hydrodissecting the plane
between rectus muscle and posterior aspect of the
RS (Fig. 23.19). Be careful not to inject too deep
under the deepest hyperechoic line that moves
with breathing. The procedure should be repeated
on the other side.
Medication 0.1–0.2 ml/kg of 0.2 % or 0.5 %ropivacaine, 0.25 % bupivacaine, or 0.25 % levobupivacaine based on the patient’s age, weight, and
the surgical procedure, for a maximum of 10 ml/
side. Concentration of 0.5 % for ropivacaine is
recommended for longer duration of analgesia.
Fig. 23.18 Lateral to medial needle orientation for rectus
sheath nerve block
Complications Skin bruises, hematoma, intravascular and intraperitoneal injection, perforation of stomach, colon, puncture of mesenteric
vessels, retroperitoneal hematoma.
Scientific Literature in Children Willschke
et al. described the considerable advantages of
ultrasound over the conventional landmark techniques for RS blocks performed for umbilical
hernia repair [27].
Important Points The bilateral single injection RS blocks should not be used for postoperative analgesia for midline abdominal incisions
from the xyphoid superiorly to the symphysis
pubis inferiorly. If RS blocks are desired, mul-
Fig. 23.17 Ultrasound anatomy of rectus sheath block: 1
adipose tissue; 2 rectus muscle
Fig. 23.19 Local anesthetic hydrodissecting posterior
rectus sheath: 1 adipose tissue; 2 rectus muscle; 3 needle;
4 local anesthetic
27323 Regional Blocks for Postoperative Pain Control
tiple injections should be performed instead, at
the same level as the incision, just lateral to the
incision. These blocks do not provide anesthesia
of peritoneum and viscera. They do not provide
analgesia for the lateral abdomen, but can be
combined with TAP blocks.
Ilioinguinal/Iliohypogastric Nerve Blocks
Introduction Ilioinguinal/iliohypogastric nerve
blocks provide ipsilateral analgesia in the inguinal area. A relatively high failure rate of 10–25 %
has been reported with a conventional “pop”
technique.
Anatomy Ilioinguinal (L1) and Iliohypogastric
(T12-L1) are branches of the lumbar plexus. They
exit the neuroaxis between the iliacus and psoas
muscle. They pierce the transversus abdominis
muscle to run in the TAP plane. The iliohypogastric then pierce the internal oblique muscle and
run under the external oblique muscle, superior
to the inguinal canal. The ilioinguinal nerve continues in the inguinal canal.
Fig. 23.20 Ultrasound probe position for ilioinguinal/
iliohypogastric nerve block
Indication Inguinal hernia repair, orchidopexy,
hydrocelectomy, and varicelectomy.
Ultrasound Techniques In-plane.
Ultrasound Probe High-frequency linear probe
(15/13−6 MHz), small footprint for patients less
than 20−30 kg.
Patient Position Supine.
Step-by-Step Technique:
The probe is placed over the bony prominence of
the anterior superior iliac spine (ASIS) and rotated so the one side rests on the ASIS and the other
side points at the umbilicus (Fig. 23.20). The
bony iliac crest is maintained on the lateral part of
the ultrasound image and the probe is moved cranial and caudal until the layers of abdominal wall
Fig. 23.21 Ultrasound anatomy of ilioinguinal, ilio-
hypogastric nerves: 1 adipose tissue; 2 external oblique
muscle; 3 internal oblique muscle; 4 ilioinguinal and Iliohypogastric nerves; 5 transversus abdominis muscle; 6
iliacus muscle
can be identified. The first muscle layer is the external oblique, next lies the internal oblique, and
deep is the transversus abdominis. The nerves
are located between the internal oblique and the
transversus abdominis (Fig. 23.21). They are very
closely related to the iliac crest and sometimes
appear as a hypoechoic (dark) with bright covering and sometimes as bright (hyperechoic) thickness between the two muscle layers. The needle
is advanced from medial to lateral, or from lateral
to medial, until it enters the fascial plane between
the internal oblique and the transversus abdominis (Fig. 23.22). Inject the medication in this
274 M. Visoiu
Fig. 23.22 Medial to lateral needle orientation for ilioin-
guinal/iliohypogastric nerve block
plane. Due to the depth of these nerves, an out-of
plane can be utilized. The target structures should
be placed in the middle of the ultrasound probe.
Medication 0.1–0.2 ml/kg of 0.2 % or 0.5 % ropivacaine, 0.25 % bupivacaine, or 0.25 % levobupivacaine based on the patient’s age, weight, and
the surgical procedure.
Complications Visceral perforation, femoral
nerve blockade; abdominal wall puncture hematoma, and infections.
Scientific Literature in Children Weintraud
et al. showed that accurate placement of local
anesthetic around the ilioinguinal/iliohypogastric
nerves is seldom possible when landmark-based
techniques are used [28].
Important Points There is high inter-individual
rate variability in nerve location and the nerves
are closer to the ASIS than previously described
[29]. Attempt to do these blocks as lateral possible. These blocks do not abolish visceral pain
due to traction of spermatic cord.
Summary
Children experience significant postoperative
pain and effective analgesia is necessary for optimal recovery. A multimodal approach that in-
cludes ultrasound guided PNBs is a better therapeutic regimen by simultaneously improving analgesia and reducing side effects from opioid use.
In addition, PNBs, a form of regional analgesia, improves quality of care, increases satisfaction and saves health care costs. Furthermore,
ultrasound technology improves accuracy and efficacy, decreases the amount of local anesthetic,
and offers additional safety benefits.
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An Introduction to Intraoperative Ultrasound
Marcus M. Malek and Marcus D. Jarboe
24
Introduction
Surgeons use many tools in the operating room.
These surgical tools help with dissection, ligation, exposure, visualization, and other aspects
of the operation. Different situations call for different tools for different surgeons. Ultrasound is
one such tool that can have countless uses in the
operating room. If a surgeon is comfortable using
intraoperative ultrasound, it can provide incredibly valuable information that has a significant
impact on the operation. In the adult literature,
diagnostic laparoscopy with laparoscopic ultrasound has been shown to be valuable in many
settings (Figs. 24.1 and 24.2) [1, 2]. For example,
intraoperative ultrasound has had a significant effect on the treatment of adult gastric cancer. As
many as 40 % of patients are upstaged by diagnostic laparoscopy with ultrasound, and about
25 % are spared a laparotomy in cases where the
disease was previously thought to be resectable
[3–6]. There is no limit to the uses of ultrasound
M. M. Malek ()
Department of Surgery, Pediatric Surgery Oncology,
Children’s Hospital of Pittsburgh of UPMC, University
of Pittsburgh School of Medicine, 4401 Penn Ave,
Pittsburgh, PA 15237, USA
e-mail: marcus.malek@chp.edu
M. D. Jarboe
Division of Pediatric Surgery, C.S. Mott Children’s
Hospital, University of Michigan, 1540 E. Hospital
Drive., SPC 4211, Ann Arbor, MI 48109-4211, USA
© Springer International Publishing Switzerland 2016
S. Scholz, M. D. Jarboe (eds.), Diagnostic and Interventional Ultrasound in Pediatrics
and Pediatric Surgery, DOI 10.1007/978-3-319-21699-7_24
Fig. 24.1 Laparoscopic ultrasound probe. Notice that
the angle of the probe can be adjusted to allow for easier
positioning during laparoscopy. The ultrasound sensor is
highlighted in the inset [1]
277
278 M. M. Malek and M. D. Jarboe
Fig. 24.2 Laparoscopic ultrasound during staging laparoscopy for adult gastric cancer [2]
in the operating room. It can be utilized in any
situation where there would be benefit in identifying a lesion or fluid collection that is deep to
the visible tissues. It can also be helpful to look
for blood flow or clots within a vessel intraoperatively. In this chapter, we present a few common
uses of ultrasound in the operating room.
to guide therapy for hepatoblastoma (Fig. 24.3).
Defining the PRETEXT stage is based on knowing the liver sectors which are defined by the
portal and hepatic vein branches. The PRETEXT
stage also contains modifiers which identify how
close the tumor is to the hepatic veins, inferior
vena cava (IVC), or portal vein branches [7, 8].
Understanding these relationships is critical to
planning your resection. In the operating room,
Oncology
identifying this relationship will define which
vessels need to be taken to get an adequate resecUltrasound can have tremendous utility during
pediatric oncological surgery. Lesions within the
liver parenchyma and their relationship to the
hepatic vasculature can be identified. This will
dictate many of the important decisions one must
make for hepatic tumors, specifically whether
or not the tumor is resectable, and if so, which
vessels will need to be taken to get an adequate
resection. The pretreatment extent of disease
(PRETEXT) is the staging system currently used
tion. Once you understand which vessels need to
be taken for the tumor resection, you will know
whether a standard left or right hepatic lobecto-
my will be sufficient, or if a trisegmentectomy or
central hepatectomy are required. It is also im-
portant to note that intraoperative ultrasound may
provide more up to date information than preop-
erative imaging. It may also more clearly identify
some of the anatomic relationships of the tumor,
which may actually lead to performing a differ-
27924 An Introduction to Intraoperative Ultrasound
Fig. 24.3 PRETEXT stages. The
liver is divided into four sectors
defined by the hepatic veins.
PRETEXT stage is defined by the
number of uninvolved sectors.
(1) PRETEXT 1 tumors have three
contiguous uninvolved sectors.
(2) PRETEXT 2 tumors have two
contiguous uninvolved sectors.
(3) PRETEXT 3 tumors have one
contiguous uninvolved sector.
(4) PRETEXT 4 tumors have no
uninvolved sectors [7]
ent operation than was planned pre-operatively
(Figs. 24.4 and 24.5) [9].
For Wilms’ tumor, the role of ultrasound to
identify tumor thrombus in the renal vein and
IVC has already been well established [10].
Intravascular extension of tumor thrombus occurs in 4–11 % of children with Wilms’ tumor
[11, 12]. Intraoperative ultrasound can be used
to confirm the extent of tumor thrombus in the
operating room, or alternatively to confirm the
lack of tumor thrombus before ligating and tran-
secting the renal vein. This point is important,
because accidental encounter of renal vein tumor
thrombus during vessel ligation and transection
will upstage the patient to a local stage III tumor,
which necessitates flank radiation and the addition of doxorubicin and its inherent risk for cardiac toxicity. Conversely, the presence of intravascular extension does not affect the prognosis if it
is successfully resected [13]. Identifying tumor
thrombus while ligating the renal vein has been
previously reported, and can be avoided with the
intraoperative use of ultrasound [14].
Fig. 24.4 Findings on intraoperative ultrasound. a Pre-
operative MRI showed extension of hepatoblastoma into
segment IVa. b Intraoperative ultrasound showed tumor
extending near but not beyond the left hepatic vein, meaning there was no segment IVa involvement. This allowed
an adequate resection with a left lateral segmentectomy as
opposed to the original plan for a left hemihepatectomy [9]
Fig. 24.5 Findings on intraoperative ultrasound. a Single
adenoma (asterisk) identified on preoperative MRI. b
Intraoperative ultrasound identified multiple additional
adenomas (arrows). This patient was diagnosed with diffuse adenomatosis and will require biannual ultrasound
surveillance [9]