Innervated vastus lateralis muscle: complementing and completing the anterolateral thigh flap for abdominal wall reconstruction.

Reconstruction of composite abdominal wall defects is challenging. An anterolateral thigh (ALT) flap has established itself in the algorithm for abdominal wall reconstruction. Augmenting innervated vastus lateralis (iVL) muscle to ALT has added advantages. We describe previously unreported advantage of ALT with iVL.A woman in her 30s, suffering from Mullerian adenocarcinoma with metastasis to the right anterior abdominal wall and right inguinal lymph node, was taken for wide local excision and reconstruction. After excision, there was a 15×12 cm defect of the anterior abdominal wall. We reconstructed the defect with prosthetic mesh and pedicled composite ALT and iVL. There was venous congestion in the ALT flap and it could not be salvaged. We debrided the ALT flap and applied split skin graft over iVL. The grafted and donor sites healed well. The patient was able to do moderate strenuous activities. The presence of iVL allowed us to get away with minor procedure and averted the need for another flap.

Case Series of Multicontact Peripheral Nerve Stimulation in the Transversus Abdominis Plane for Chronic Abdominal Wall Pain.

OBJECTIVES: Managing abdominal pain can be difficult. This is due to the nonspecific nature of the pain, the multiple etiologies, and the different mechanisms underlying this type of pain. Abdominal wall pain in particular poses its own challenges. Traditionally, chronic abdominal wall pain has been managed with nonopioid analgesics, and in severe cases, opioid therapy has been considered. For patients with chronic abdominal wall pain refractory to medication management, peripheral nerve blocks and spinal cord stimulation also have been trialed with some success. In this study, we present a case series in patients with chronic abdominal wall pain who were treated with a multicontact peripheral nerve stimulation (PNS) system in the transversus abdominis plane (TAP). MATERIALS AND METHODS: This was a single-center, retrospective case series. Data were included from adults with chronic abdominal wall pain whose symptoms were refractory to standard medical management and who underwent a multicontact PNS system placement in the TAP. RESULTS: Four patients met the inclusion criteria. All four patients underwent a multicontact PNS trial lead placement in the TAP. One patient reported no benefit from the trial. The remaining three patients underwent a permanent multicontact PNS system placement in the TAP. CONCLUSIONS: In patients with chronic abdominal wall pain whose symptoms are refractory to conservative medical management, PNS may be an alternative treatment option. As the use of PNS for chronic abdominal wall pain and other fascial planes continues to develop, additional research is necessary to determine optimal placements and specific stimulation parameters.

Anterior cutaneous nerve entrapment syndrome in children.

QUESTION: I frequently see adolescents with recurrent abdominal pain in my family medicine clinic. While the diagnosis frequently is a benign condition such as constipation, I recently heard that after 2 years of recurrent pain, an adolescent was diagnosed with anterior cutaneous nerve entrapment syndrome (ACNES). How is this condition diagnosed? What is the recommended treatment? ANSWER: Anterior cutaneous nerve entrapment syndrome, first described almost 100 years ago, is caused by entrapment of the anterior branch of the abdominal cutaneous nerve as it pierces the anterior rectus abdominis muscle fascia. The limited awareness of the condition in North America results in misdiagnosis and delayed diagnosis. Carnett sign-in which pain worsens when using a "hook-shaped" finger to palpate a purposefully tense abdominal wall-helps to confirm if pain originates from the abdominal viscera or from the abdominal wall. Acetaminophen and nonsteroidal anti-inflammatory drugs were not found to be effective, but ultrasound-guided local anesthetic injections seem to be an effective and safe treatment for ACNES, resulting in relief of pain in most adolescents. For those with ACNES and ongoing pain, surgical cutaneous neurectomy by a pediatric surgeon should be considered.

Novel external oblique muscle plane block for blockade of the lateral abdominal wall: a pilot study on volunteers.

PURPOSE: No reports have described techniques to efficiently anesthetize the lateral cutaneous branches of the entire abdomen. The aim of this study was to investigate an effective procedure for blocking the lateral cutaneous branches in the abdominal region. We sought to describe the sensory distribution of the previously described thoracoabdominal nerve block through perichondrial approach (TAPA) and the novel costal and lateral external oblique muscle plane (EXOP) blocks in healthy volunteers. METHODS: This was a proof-of-concept pilot study that comprised ten volunteers with an American Society of Anesthesiologists Physical Status I. The participants underwent modified TAPA (M-TAPA), injection 2 of TAPA (injection into the anterior aspect of the 10th costal cartilage: I2-TAPA), costal EXOP, and lateral EXOP blocks with injection of 20 mL of ropivacaine 0.2% for each block. A pinprick test was performed one hour after injection and repeated at 30-min intervals until the effect of the nerve block disappeared. RESULTS: The M-TAPA injection anesthetized the anterior branches from T6/7 to T11/12, whereas the I2-TAPA injection had no effect. Costal and lateral EXOP injections anesthetized the lateral cutaneous branches of T7-10 and T11-12, respectively. CONCLUSION: The results of this pilot study in ten healthy volunteers indicate that novel EXOP blocks involving local anesthetic injection superficial to the external oblique muscle efficiently anesthetize the lateral cutaneous branches of the thoracoabdominal nerves. Our study shows that it may be anatomically plausible for the combined use of these blocks to anesthetize the entire abdominal wall.

RéSUMé: OBJECTIF: Aucune présentation de cas n'a décrit de techniques permettant l'anesthésie efficace des branches cutanées latérales de tout l'abdomen. L'objectif de cette étude était d'évaluer une procédure efficace pour bloquer les branches cutanées latérales de la région abdominale. Nous avons cherché à décrire la distribution sensorielle du bloc nerveux thoraco-abdominal par approche périchondrale (TAPA), décrit précédemment, et des nouveaux blocs du plan musculaire oblique externe (EXOP) costal et latéral réalisés chez des volontaires sains. MéTHODE: Il s'agissait d'une étude pilote de preuve de concept qui comprenait dix volontaires avec un statut physique I selon l'American Society of Anesthesiologists. Les participants ont bénéficié d'un bloc TAPA modifié (M-TAPA), de l'injection 2 d'un bloc TAPA (injection dans l'aspect antérieur du 10e cartilage costal : I2-TAPA), d'un bloc EXOP costal et d'un bloc EXOP latéral avec injection de 20 mL de ropivacaïne 0,2 % pour chaque bloc. Un test cutané par piqûre d'épingle a été réalisé une heure après l'injection et répété à des intervalles de 30 minutes jusqu'à ce que l'effet du bloc nerveux disparaisse. RéSULTATS: L'injection de M-TAPA a anesthésié les branches antérieures de T6/7 à T11/12, tandis que l'injection d'I2-TAPA n'a eu aucun effet. Les injections costales et latérales d'EXOP ont anesthésié les branches cutanées latérales de T7­10 et T11­12, respectivement. CONCLUSION: Les résultats de cette étude pilote chez dix volontaires sains indiquent que les nouveaux blocs EXOP avec une injection superficielle d'anesthésique local au muscle oblique externe anesthésient efficacement les branches cutanées latérales des nerfs thoraco-abdominaux. Notre étude montre qu'il peut être anatomiquement plausible de combiner ces blocs pour anesthésier toute la paroi abdominale.

[ACNES syndrome, exploring the abdominal wall as source of abdominal pain]. / Síndrome de ACNES, explorando la pared abdominal como noxa del dolor abdominal.

Abdominal wall pain, specifically ACNES syndrome (Anterior Cutaneous Nerve Entrapment Syn drome), is part of the differential diagnosis of chronic abdominal pain. This syndrome is frequently overlooked and therefore underdiagnosed. OBJECTIVES: To describe the clinical and evolutionary cha racteristics of patients diagnosed with ACNES and to draw attention to this pathology. PATIENTS AND METHOD: A retrospective descriptive study was carried out in a reference center, between October 2016 and July 2021, in patients under 17 years of age, diagnosed with ACNES, who met at least two of four of the following findings: Carnett's sign, Pinch test, dysesthesia at the point of maximum pain, improvement after infiltration of local anesthetic, having ruled out visceral or functional abdo minal pathology. Epidemiological variables, symptoms, physical examination, complementary tests, treatment, and evolution data were collected. Descriptive statistics were used. RESULTS: 20 patients diagnosed with ACNES, 75% women, median age 12.85 years. The abdominal examination revea led Carnett's sign in 95%, Pinch test sign in 65%, and dysesthesia in 90% of patients. 65% reported pseudovisceral symptoms. 7 patients were overweight or obese. The most frequent location (50%) was the right iliac fossa, at T10-T11 level. One patient reported spontaneous improvement; 7 impro ved with oral analgesia; 9 patients were referred to the pain unit, of which 5 attended, and improved with anesthetic infiltration with bupivacaine-triamcinolone. The remaining 4 were lost to follow-up. CONCLUSION: ACNES should be considered in patients with chronic pain. A combination of typical findings in medical history and physical examination allows its diagnosis, therefore, avoiding unne cessary complementary tests. A step-up treatment strategy should be applied, beginning with oral analgesia, followed by anesthetic infiltration, and, finally, anterior neurectomy.

Regional Anesthesia Abdominal Blocks and Local Infiltration After Cesarean Delivery: Review of Current Evidence.

PURPOSE OF REVIEW: In this review, we discuss surgical infiltration and various abdominal wall blocks, including transversus abdominis plane (TAP) block and quadratus lumborum blocks, and review the literature on the evidence behind these approaches and analgesia for cesarean delivery (CD). RECENT FINDINGS: Adequate pain management in the parturient following CD is important to facilitate early ambulation and neonatal care while also improving patient satisfaction and decreasing hospital length of stay. Neuraxial opioids have been a mainstay for postoperative analgesia; however, this option may not be available for patients undergoing emergency CD and have contraindications to neuraxial approaches, refusing an epidural or spinal, or with technical difficulties for neuraxial placement. In such cases, alternative options include a fascial plane block or surgical wound infiltration. The use of regional blocks or surgical wound infiltration is especially recommended in the parturient who does not receive neuraxial opioids for CD. Adequate postoperative analgesia following CD is an important component of the overall care of the parturient as it helps facilitate early mobilization and improve patient satisfaction. In conclusion, the use of abdominal fascial plane blocks or surgical wound infiltration is recommended in the parturient who does not receive neuraxial opioids for CD.

Characteristics of 1116 Consecutive Patients Diagnosed With Anterior Cutaneous Nerve Entrapment Syndrome (ACNES).

OBJECTIVE: The aim of this study was to discuss patient history and subjective findings at physical examination in a large case series to validate a proposed comprehensive set of major and minor diagnostic criteria. SUMMARY BACKGROUND DATA: Chronic abdominal pain in some patients is caused by the anterior cutaneous nerve entrapment syndrome (ACNES). ACNES is a clinical diagnosis as no functional testing or imaging modalities are available up to date. METHODS: This study retrospectively analyzed prospectively obtained data from consecutive patients who received the diagnosis ACNES during evaluation at the SolviMáx Center of Excellence for Abdominal Wall and Groin Pain, Eindhoven, The Netherlands, between June 1, 2011 and September 1, 2016. Questionnaires, standard case forms, and digital case files containing characteristics of individuals were used for analysis. RESULTS: Data of 1116 patients suspected and treated for ACNES consistently showed the presence of the following 4 characteristics: sensory disturbances at the painful abdominal area (78%), a positive pinch sign (78%), a positive Carnett's sign (87%), and a positive response to a modified rectus sheath block (>50% pain reduction, 81%). The majority of patients are female of young or middle age with a normal BMI reporting complaints that occurred spontaneously in either a sudden or gradual timeframe, developing a severe (NRS 6-8) chronic abdominal pain that was only diagnosed after a substantial doctor's delay. CONCLUSION: A combination of typical findings in history and physical examination, combined with a positive modified rectus sheath block, may allow for diagnosing ACNES in patients with chronic abdominal pain.

Laparoscopic-guided versus transincisional rectus sheath block for pediatric single-incision laparoscopic cholecystectomy: A randomized controlled trial.

PURPOSE: The purpose of our study was to compare the effectiveness of transincisional (TI) versus laparoscopic-guided (LG) rectus sheath block (RSB) for pain control following pediatric single-incision laparoscopic cholecystectomy (SILC). METHODS: Forty-eight patients 10-21 years old presenting to a single institution for SILC from 2015 to 2018 were randomized to TI or LG RSB. Apart from RSB technique, perioperative care protocols were identical between groups. Pain scores were assessed with validated measures upon arrival in the postanesthesia care unit (PACU) and at regular intervals until discharge. The patients and those assessing them were blinded to RSB technique. The primary outcome was pain score 60 min after PACU arrival. Secondary outcomes included pain scores throughout the PACU stay, opioids (reported as morphine milligram equivalents (MME) per kg bodyweight) administered in PACU, length of stay, outpatient pain scores and opioid use, and adverse events. Groups were compared on outcomes using t test and generalized estimating equations for continuous variables and Fisher's exact test for categorical variables with significance at α = 0.05. RESULTS: Mean age of the 48 subjects was 15 years (range = 11-20). The majority (79%) were female. Indications for surgery included symptomatic cholelithiasis (n = 41), acute cholecystitis (n = 4), gallstone pancreatitis (n = 2) and choledocholithiasis (n = 1). Mean (standard deviation) operative time was 61 (±23) min overall. No statistically significant differences in demographics, indication, operative time, or intraoperative analgesia were observed between TI (n = 24) and LG (n = 24) groups. The mean 60-min pain score was 3.4 (±2.6) in the LG group versus 3.8 (±2.1) in the TI group (p = 0.573). No significant differences were detected between groups in overall PACU or outpatient pain scores, PACU or outpatient opioid use, length of stay, or incidence of complications. Overall, mean opioid use was 0.1 MME/kg in the PACU and 0.5 MME/kg in the outpatient setting. Mean postoperative length of stay was 0.2 day. There were no major complications. CONCLUSION: Laparoscopic-guided rectus sheath block is not superior to transincisional rectus sheath block for pain control following pediatric single-incision laparoscopic cholecystectomy. The single-incision laparoscopic approach combined with rectus sheath block resulted in effective pain control, low opioid use, and expedited length of stay with no major complications. LEVEL OF EVIDENCE: Level I, treatment study, randomized controlled trial.

The technique of cutaneous neurectomy for anterior cutaneous nerve entrapment syndrome.

Anterior cutaneous nerve entrapment syndrome (ACNES) is increasingly diagnosed in children. Pediatric surgeons may be approached to perform a cutaneous neurectomy, the preferred operative approach, and may have no experience with the procedure. This report provides a detailed description of the operative technique used by a pediatric surgeon who has performed over 70 neurectomies for ACNES. Dissemination of this simple procedure will hopefully allow children with ACNES to undergo the procedure locally.

Neurolytic abdominal wall blocks with alcohol for intractable gastrostomy site pain in a cancer patient -a case report.

BACKGROUND: There have been reports of neurolytic transversus abdominis plane (TAP) block using different agents such as alcohol or phenol for the treatment of chronic abdominal pain caused by malignant abdominal wall invasion. However, to date, there have been no reports on neurolytic abdominal wall blocks for pain with non-cancer-related origin in cancer patients. CASE: We performed subcostal TAP neurolysis using ethanol in a patient with esophageal cancer with constant pain at the site of gastrostomy. After neurolysis, the patient's overall pain decreased, with the exception of pain in the medial part of the gastrostomy site. We performed additional rectus sheath neurolysis using ethanol for the treatment of continuous pain at the medial site, and the effect of neurolysis has persisted for over 4 months. CONCLUSIONS: Alcohol-based TAP neurolysis and rectus sheath neurolysis provide effective pain control in a cancer patient with chronic treatment-related pain involving the abdominal wall.

Study of abdominal wall muscle innervation applied to large-defect closure in congenital diaphragmatic hernia.

In large congenital diaphragmatic hernias (CDHs), direct suture of the diaphragm is impossible. Surgeons can use a triangular internal oblique muscle (IOM) plus transverse abdominis muscle (TAM) flap. Its caudal limit faces the medial extremity of the 11th rib. Clinical studies show that the flap is not hypotonic but that the procedure could expose patients already presenting a hypoplastic lung to external oblique muscle (EOM) hypotonia. The aims of this study were to study EOM innervation by the 10th intercostal nerve (ICN) and ICN innervation to the IOM and TAM. Forty cadaveric abdominal hemi-walls were dissected. The number of branches and the trajectory of each specimen's 10th ICN were studied medially to the medial extremity of the 11th rib (MEK11) using surgical goggles and a microscope (Carl Zeiss®). The 10th ICN was consistently found between the IOM and TAM. There was a median of nine branches from the 10th ICN to the EOM, 77% of them medial to the MEK11. Median values of nine and 12 branches for the IOM and TAM were found, 60% and 51%, respectively, medial to the MEK11. These results argue in favor of good innervation to the IOM plus TAM flap but also indicate postoperative abdominal weakness exposing patients to herniation risks, as more than 75% of the branches from the 10th ICN to the EOM were sectioned or pulled away during flap detachment. Clin. Anat., 33:759-766, 2020. © 2019 Wiley Periodicals, Inc.

Bloqueos de tronco / Truncal blocks

Truncal blocks have recently been positioned as an alternative to neuraxial analgesia. The injection of local anesthetics in interfascial planes was initially guided by anatomical landmarks, to later evolve towards a more selective administration when guided by ultrasound. Successful execution of truncal blocks requires detailed knowledge of the chest and abdominal walls anatomy. The same logic allows us to understand its potential benefits concerning perioperative analgesia, as well as its limitations and therapeutic margins. Secondary to a growing interest in less invasive techniques and analgesic techniques with a more favorable risk-benefit profile, the available evidence in this field is in continuous development. Thus, in the present review, the technical aspects of these blocks will be evaluated, emphasizing the sonoanatomy, and assessing the best evidence to support the use of each technique.

Los bloqueos de tronco se han posicionado recientemente como una alternativa frente a la analgesia neuroaxial. La inyección de anestésicos locales en planos interfasciales inicialmente fue guiado por referencias anatómicas, para posteriormente evolucionar hacia una administración más selectiva al ser guiada por el ultrasonido. La ejecución exitosa de los bloqueos de tronco requiere un conocimiento detallado de la anatomía de las paredes del tórax y abdomen. Esta misma lógica nos permite entender sus potenciales beneficios en relación con la analgesia perioperatoria, como también sus limitaciones y margen terapéutico. La evidencia disponible está en continuo desarrollo, dado el creciente interés que concitan técnicas menos invasivas y con un perfil de riesgo-beneficio potencialmente más favorable. En la presente revisión se evaluarán los aspectos técnicos de cada bloqueo, poniendo énfasis en la sonoanatomía, y evaluando la mejor evidencia que sustente el uso de cada técnica.

Modified Makuuchi incision for major upper abdominal surgeries.

ackground: Numerous incisions are described for abdominal operations. However, opinion is divided regarding the correct choice of incision for major upper abdominal surgeries. MATERIALS AND METHODS: Experience of 3 surgical centres with the use of modified Makuuchi incision, for major upper abdominal surgeries, from Mar 2014-Dec 2018, was audited. RESULTS: 144 patients (76 Males, 68 Females) with an average age of 48.25 years underwent surgery using modified Makuuchi incision. 'J' and 'L' incisions were used in 96 and 48 patients, respectively. Further extension of the incision was necessary in 2 patients. Adequate exposure and enhanced surgical ergonomics was observed in all cases. Surgical site infection was seen in 19 patients (13.2%). Incisional hernias was observed in 6 patients (4.2%), on an average follow up of 27.78 months. CONCLUSIONS: Modified Makuuchi incision proves efficacious for major upper abdominal surgeries.

Sedation and paralytic use in open abdomen patients-results from the EAST SLEEP Survey.

BACKGROUND: Patients with an open abdomen after trauma or emergency surgery may benefit from reduced sedation and chemical paralysis. We studied the effect of attending surgeon experience on sedation depth and paralytic use, as well as enteral nutrition and time between laparotomies. METHODS: We performed an institutional review board-approved survey (Sedation Level after Emergent ExLap without Primary Fascial Closure) of the senior and active Eastern Association for the Surgery of Trauma membership using Qualtrics (Qualtrics, Inc, Provo, UT). We obtained 393/1,655 responses (23.7%). Spearman's rho was used for ordinal data, and multivariate logistic regression was used to adjust for trauma center level and presence of trainees in the relationship between surgeon experience and use of deep sedation. RESULTS: Surgeon experience was associated with deep sedation (Richmond Agitation and Sedation Score ≤-3, P = .001) and chemical paralysis (P = .001). Surgeon experience was associated with less concern about delirium and more concern for evisceration as the reason for sedation depth (P = .001) and for paralysis (P = .001). Using multivariate logistic regression, surgeon experience was associated with deep sedation (odds ratio 3.6 [95% confidence interval 1.3, 10.4], P = .017 for ≥20 years; odds ratio 3.5 [95% confidence interval 1.1, 10.4], P = .025 for 15-20 years). Trauma center level was also significant (odds ratio 7.2 for Richmond Agitation and Sedation Score ≤-3 [95% confidence interval 1.7, 31.0], P = .008 for level III/IV versus level I/II). Increased surgeon experience was associated with delay of commencement of enteral feeds until return of bowel function (P = .013). Few respondents indicated willingness to extubate or mobilize open abdomen patients. Experienced surgeons were likely to wait for a defined time rather than for normalization of resuscitation markers to perform the first takeback laparotomy (P = .047) and waited longer between subsequent laparotomies (P = .004). CONCLUSION: There were significant variations in practice among respondents based on the length of time since their last residency or fellowship, including variations that deviate from current best practice for management of patients with an open abdomen.

Impact of Ultrasound-Guided Transversus Abdominis Plane Block on Postoperative Pain and Early Outcome After Laparoscopic Bariatric Surgery: a Randomized Double-Blinded Controlled Trial.

BACKGROUND: Based on the promising results of transversus abdominis plane (TAP) block in various abdominal procedures, this study aimed to investigate its effect on postoperative pain and early outcome after laparoscopic bariatric procedures. METHODS: Patients with morbid obesity were randomly assigned to one of two equal groups; group I had US-guided TAP block upon completion of the bariatric procedure and before recovery from general anesthesia and group II did not have TAP block. All procedures were performed laparoscopically with a standardized five-trocar technique. RESULTS: Ninety-two patients of a mean age of 34.7 years and mean BMI of 49.5 kg/m2 were included. The mean pain score in group I was significantly lower than group II at 1 and 6 h postoperatively, whereas no significant differences in pains scores at 12 and 24 h between the two groups were observed. Eight patients in group I required rescue opioid analgesia within the first 24 h postoperatively, compared with 24 patients in group II (P < 0.0001). The postoperative nausea and vomiting (PONV) score at 24 h was significantly lower in group I than group II. Group I required a significantly shorter time to full ambulation and to pass flatus compared with group II. Hospital stay was similar in the two groups. CONCLUSION: Using US-guided TAP block in adjunct with laparoscopic bariatric surgery managed to achieve lower pain scores, lower opioid requirements, lower PONV scores, earlier ambulation, shorter time to pass flatus, and comparable hospital stay and complication rate to the control group.