Surgeon performed rectus blocks reduce same day admission rates after laparoscopic ventral hernia repairs, a case series of 52 patients.

Matthew Kasulke, MD, David Ryan, MD, Ibrahim Daoud, MD. St. Francis Hospital

Overview:  Analgesic nerve blocks reduce post-operative opioid use while fostering patient mobilization and comfort.  We performed rectus sheath blocks under laparoscopic vision during ventral hernia repairs.  Traditionally this procedure requires 2-3 days of hospitalization for analgesia.  Our technique facilitates same day discharge and reduces OR time since it is performed intra-operatively without special equipment and personnel (i.e. ultrasound/anesthetists).

Methods:  All patients undergoing laparoscopic ventral hernia repair with mesh from 1/2015 to 8/2015 were included.  Fascia was not closed and rectus blocks were performed before affixing mesh.  Age, race, sex, weight, BMI, ASA classification, ventral hernia type, comorbidities, admission rate, length of stay, readmission rates, procedure length, recovery room time, adhesiolysis amount, mesh type, device for mesh fixation, intra-operative analgesia, rectus block anesthesia amount/type, recovery room analgesia, and postoperative complications were recorded. 

Results:  52 patients were included with a median age of 50.5 years (53.8% female).  Median weight and BMI were 86.5kg and 29.51 kg/m2.  11.5% of subjects were ASA 1, 80.8% ASA 2, 5.8% ASA 3, and 1.9% ASA 4.  3 patients were admitted from recovery room and were ASA 2.  One patient was re-admitted for biliary colic 21 days post operatively.  Two patients went to the ER 4 days out and were discharged from there (nausea/chest pain).

Median length of procedure was 42 minutes and median recovery room stay was 109.5 minutes.  All employed the SorbaFix device for mesh fixation except for two in which; 1) ProTack and 2) SorbaFix plus Tisseel were used.  Mesh was 15 x 20cm Ventralight (n=3), 20 x 25cm Ventralight (n=4), 11.4cm Ventrio ST (n=40), or 11 x 14cm oval Ventrio ST (n=5).

Intraoperative analgesia ranged from 100mcg fentanyl administered once to fentanyl, 1mg dilaudid, 30mg Toradol, and 1000mg Ofirmarev administered per operation. 

51 of 52 patients were given the rectus block:  30ml of 0.5% Bupivacaine with epinephrine (n=42) or 30ml of 0.25% Bupivacaine with epinephrine (n=9).

Recovery room analgesia ranged from none to 1.5 mg dilaudid and 5mg oxycodone.  3 received 30mg Toradol and 6 received Norflex 30mg.

Conclusion:  Our study is limited by low sample size and its non-blinded, single surgeon/institution potential biases.  The technique is effective, inexpensive, and efficient.  Similar anesthetic “blocks” like the transversis abdominus and pediatric rectus blocks are proven clinically.  Our goal is to expose a new technique that may improve analgesia and decrease admission rates after this painful operation.  We hope our experience prompts further investigation.

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