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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.58 no.1 Campinas Jan./Feb. 2008
Ultrasound-guided ileoinguinal and ileohypogastric nerve block associated with general anesthesia. Case report*
Bloqueo de los nervios íleoinguinal e íleohipogástrico guiado por ultrasonografía asociado a anestesia general. Relato de caso
Diogo Brüggemann da Conceição; Pablo Escovedo Helayel, TSA
Anestesiologista do CET Integrado de Anestesiologia da SES-SC; Membro do Núcleo de Ensino e Pesquisa em Anestesia Regional do HGCR
OBJECTIVES: Outpatient surgeries are becoming more frequent. Ilioinguinal
and iliohypogastric nerve block has been used in postoperative analgesia of
patients undergoing outpatient inguinal herniorrhaphy. Ultrasound-guided regional
anesthesia increases the accuracy of deposition of the local anesthetic around
the nerves. The objective of this report was to present a case of ultrasound-guided
ilioinguinal and iliohypogastric nerve block for outpatient inguinal herniorrhaphy.
CASE REPORT: A 36-year old male patient, 74 kg, physical status ASA I, was scheduled for inguinal herniorrhaphy. Ultrasound-guided iliohypogastric and ilioinguinal nerve block was accomplished with 0.5% ropivacaine, followed by total intravenous anesthesia. The patient was discharged from the hospital 4 hours after the procedure with a pain score of 3 in the Verbal Analogue Scale.
CONCLUSION: Ultrasound-guided iliohypogastric and ilioinguinal nerve block in patients undergoing outpatient inguinal herniorrhaphy can be done as an aid to postoperative analgesia.
Key Words: ANESTHETIC TECHNIQUES, Regional: ilioinguinal nerve block, iliohypogastric nerve block; SURGERY, General: inguinal herniorrhaphy.
Y OBJETIVOS: Procedimientos quirúrgicos realizados en régimen
ambulatorial se están convirtiendo cada vez más frecuentes. El
bloqueo de los nervios íleoinguinal e íleohipogástrico
ha sido usado para la analgesia postoperatoria de pacientes sometidos a la herniorrafia
inguinal en régimen ambulatorial. La ultrasonografía auxilia las
técnicas de anestesia regional posibilitando una mayor precisión
en el depósito del anestésico local el rededor de los nervios.
El objetivo de este relato fue presentar un caso de bloqueo de los nervios íleoinguinal
e íleohipogástrico guiado por ultrasonografía en paciente
a realizar herniorrafia inguinal en régimen ambulatorial.
RELATO DEL CASO: Paciente del sexo masculino, 36 años, 74 kg, estado físico ASA I, listo para la realización de herniorrafia inguinal. Fue realizado el bloqueo de los nervios íleohipogástrico e íleoinguinal guiado por ultrasonografía con ropivacaína a 0,5% y enseguida fue realizada anestesia venosa total. El paciente tuvo alta 4 horas después del procedimiento con puntuación de dolor evaluado por la Escala Analógica Verbal de 3.
CONCLUSIONES: El bloqueo de los nervios íleohipogástrico e íleoinguinal guiados por ultrasonografía en pacientes sometidos a herniorrafia inguinal en régimen ambulatorial, puede ser utilizado en el auxilio del control del dolor postoperatorio.
Outpatient surgeries are becoming more frequent due to the development of less invasive surgical techniques, better control of postoperative pain and the need to decrease costs 1.
Ilioinguinal (II) and iliohypogastric (IH) nerve block has been used as an aid to postoperative analgesia and for early hospital discharge of patients undergoing outpatient inguinal herniorrhaphy.
Most techniques described for the blockade of those nerves are carried out based on anatomical references through fascial clicks, with a failure rate above 20% in the pediatric population 2.
The development of high-frequency ultrasound transducers made it possible the visualization of superficial nerves 3. Recently, an ultrasound-guided selective block of the II and IH nerves has been described 4.
The objective of this study was to report a case of ultrasound-guided ilioinguinal and iliohypogastric nerve block in a patient scheduled for outpatient inguinal herniorrhaphy.
A 36-year old male patient, weighing 74 kg, with 1.75 m, physical status ASA I, scheduled for right inguinal herniorrhaphy.
After monitoring (cardioscope, non-invasive blood pressure and pulse oximetry) and sedation with midazolam (0.05 mg.kg-1), an ultrasound-guided II and IH nerve block as described by Eichenberger et al. 4 was performed.
A conventional ultrasound equipment (Sonoace 8000 SE Medsom) with a 4-cm broad band (7-12 MHz) linear transducer was used.
With the patient in dorsal decubitus, the transducer was placed approximately 5 cm above the right anterior superior iliac spine in a slight rotation, from a transversal to oblique plane (Figure 1) in order to remain perpendicular to the anatomic path of the nerves. The lateral portion of the transducer was over the iliac crest. After localizing both nerves between the internal oblique and transverse abdominis muscles (Figure 2), a 5 cm non-cutting needle (Plexufix B-Braun) was introduced transversely to the transducer and 10 mL of 0.5% ropivacaine were injected on each nerve. After 15 minutes, cutaneous sensitivity in the area of the incision was tested with a 27G needle and the patient referred paresthesia.
For the surgical anesthesia, a target-controlled infusion of propofol (Diprifusor Astra Zeneca) and alfentanil 20 µg.kg-1 were used. A number 4 laryngeal mask and pressure-controlled ventilation were used to maintain the airways opened. Forty milligrams of intravenous tenoxicam were administered 20 minutes before the end of the surgery.
Analgesia was evaluated every 30 minutes using the Verbal Analogue Scale. The patient was discharged from the hospital four hours after the surgery with a VAS score of 3. The patient did not receive any other analgesics.
Adequate control of postoperative pain is one of the criteria for discharging patients after outpatient surgery. Regional blocks are used for this ending. Ilioinguinal and iliohypogastric nerve block is frequently used for postoperative analgesia in pediatric patients with good results 2. Its use in adult patients has been increasing due to a higher incidence of outpatient inguinal herniorrhaphy 5.
The techniques used most often for those blocks are based on anatomical references, through fascial clicks, injecting large volumes of local anesthetic and are relatively non-selective 5 and consequently carry a failure rate above 20% in pediatric patients 2.
The use of ultrasound-guided peripheral nerve blocks has been rising 3. It allows direct visualization of the nerves, detection of anatomical variations and prevents damaging structures adjacent to the nerves 3.
The technique used for the II and IH 4 nerve block allows the selective blockade of each one of the nerves. The local of injection, approximately 5 cm above the antero-superior iliac spine, facilitates ultrasound orientation since at this point all three muscle layers of the abdominal wall are present6 and can be visualized. In 95% of the cases, the II and IH nerves, at this point, are between the internal oblique and abdominis transverse muscles 4.
To conclude, the selective of the ilioinguinal and iliohypogastric nerves block provided, in this case, good quality analgesia and early discharge of the patient. The use of ultrasound as an aid to regional anesthesia promotes higher precision of local anesthetic deposition, increasing safety, both for the patient and the anesthesiologist.
01. Cangiani LM Anestesia Ambulatorial: Conceito e Aspectos Gerais, em: Cangiani LM Anestesia Ambulatorial. São Paulo, Atheneu, 2001;3-26. [ Links ]
02. Lim SL, Ng Sb A, Tan GM Ilioinguinal and iliohypogastric nerve block revisited: single shot versus double shot technique for hernia repair in children. Paediatr Anaesth, 2002;12:255-260. [ Links ]
03. Marhofer P, Greher M, Kapral S Ultrasound guidance in regional anesthesia. Br J Anaesth, 2005;94:7-17. [ Links ]
04. Eichenberger U, Greher M, Kirchmair L et al. Ultrasound-guided blocks of the ilioinguinal and iliohypogastric nerve: accuracy of a selective new technique confirmed by anatomical dissection. Br J Anaesth, 2006;97:238-243. [ Links ]
05. Toivonen J, Permi J, Rosenberg PH Effect of preincisional ilioinguinal and iliohypogastric nerve block on postoperative analgesic requirement in day-surgery patients undergoing herniorrhaphy under spinal anaesthesia. Acta Anaesthesiol Scand, 2001;45:603-607. [ Links ]
06. Gardner E Nervos do Abdome, em: Gardner E, Gray DJ, O'Rahilly Anatomia: Estudo Regional do Corpo Humano. 2ª Ed, Rio de Janeiro, Guanabara Koogan, 1967;487-493. [ Links ]
Dr. Diogo Brüggemann da Conceição
Rua Bocaiúva, 1.659/1.103
88015-530 Florianópolis, SC
Submitted em 9
de novembro de 2006
Accepted para publicação em 24 de setembro de 2007
* Received from Núcleo de Ensino e Pesquisa em Anestesia Regional do Hospital Governador Celso Ramos (HGCR), CET Integrado de Anestesiologia da SES-SC, Florianópolis, SC