Lateral Hernias
Jeff Garner, Dominic Slade in Manual of Complex Abdominal Wall Reconstruction, 2020
The traditional nephrectomy flank scar typically incises over the 11th or 12th ribs from sacrospinalis forward to the end of the ribs dividing the serratus posterior, latissimus dorsi and all three lateral abdominal wall muscles to access the retroperitoneum. The intercostal nerves run along the lower border of the ribs and branches continue anteriorly towards the umbilicus providing motor and sensory innervation. They may be injured by direct division during surgery or pressure from retraction (neuropraxia) with a rate of permanent flank bulge reported of up to 49%.18 A Swedish study of 197 successive open partial nephrectomy patients followed up for 2 years saw an initial bulge rate of 23% at 3 months decline to 2.7% at 24 months, whereas the clinical hernia rate increased from 0.6% to 4.9% over the same period19 suggesting that some of the initial clinical and radiological bulges seen were due to neuropraxia which subsequently resolved. As surgical technique has evolved, mini-incision nephrectomy utilising muscle splitting rather than division has further reduced the incisional hernia (IH) rate to 1.4%.20 Given the location of the incision, some may present intercostally, as may port site hernias from laparoscopic nephrectomy (Figure 15.15).
Critical Care of the Trauma Patient
Kenneth D Boffard in Manual of Definitive Surgical Trauma Care: Incorporating Definitive Anaesthetic Trauma Care, 2019
Early pain control in the ICU is primarily achieved using intravenous opiates, although there is emerging evidence for the use of ketamine infusion as an opiate-sparing option. Other techniques are employed and tailored to the individual patient and injury: Bolus analgo-sedation opiates and non-opiates. Morphine, fentanyl or ketamine equivalent titrated intravenously.Patient-controlled analgesia (PCA).Epidural or paraspinal analgesia (patient-controlled epidural analgesia).Intrapleural anaesthesia.Extrapleural analgesia.Intercostal nerve blocks.Catheter techniques for peripheral nerve blocks, for example, femoral nerve, brachial plexus, popliteal nerve and paravertebral nerve blocks.
Paediatric anaesthesia
Brice Antao, S Irish Michael, Anthony Lander, S Rothenberg MD Steven in Succeeding in Paediatric Surgery Examinations, 2017
Empyema occurs in about 3 per 100 000 children per year, more commonly in pre school and teenage children, and in winter and spring. Ultrasound is useful in defining the size, composition and location of the empyema. Patients usually present with severe pneumonia or pneumonia which does not respond well to antibiotics. There is neutrophilia and a markedly raised CRP. The causative organism is normally Streptococcus pneumoniae and cephalosporins are usually effective but treatment should be guided by microbiological results as atypical organisms may occur. Intercostal nerve blocks provide useful pain relief. A spontaneous breathing technique probably reduces the risk of causing bronchopulmonary fistula; if the patient is ventilated, higher than normal airway pressure will be needed because of the reduced chest compliance.
Effectiveness of adding magnesium sulfate to bupivacaine in ultrasound guided serratus anterior plane block in patients undergoing modified radical mastectomy
Published in Egyptian Journal of Anaesthesia, 2023
Rehab Abd El-Raof Abd El-Aziz, Mohamed Frouk Asal, Ayman M. Maaly
Serratus anterior plane block (SAPB) is recently introduced analgesic technique for female patients planned for breast surgeries. [8,9] The target plane of SAPB is between the serratus anterior and the latissimus dorsi muscles. [10] Its analgesic effect is produced by blocking lateral branches of thoracic intercostal nerves II, III and VI. SAPB under sonography, its anatomy is easy to be identified and reached, and the expected complications related to the pleura and central neuraxial structures can be avoided. [11,12] Different drugs as adjuvant to local anaesthetic may be used such as fentanyl, morphine and dexmedetomidine to improve the quality of regional blocks in breast surgeries, but these adjuvants may be associated with many adverse effects as nausea, vomiting and hypotension. [13–15]
Advantages and feasibility of intercostal nerve block in uniportal video-assisted thoracoscopic surgery (VATS)
Published in Postgraduate Medicine, 2023
The 4th or 5th intercostal space is used as the surgical incision site in uniportal VATS in clinical practice. Intraoperative injury to the intercostal nerve may lead to postoperative pain. The intercostal nerve is a mixed nerve branch formed by the union of the anterior and posterior roots after the thoracic spinal cord. Each intercostal nerve emerges from the intervertebral foramen and travels at the lower edge of the rib angle to the costal groove accompanying the intercostal artery. The pain felt by the nerve endings travels from the intercostal nerve to the nerve roots, spinal cord, and cerebral cortex. Therefore, ICNB is performed primarily from the rib angle. In addition, the adjacent intercostal skin is innervated by the intercostal nerve; therefore, the surrounding skin should also be blocked. Various regional analgesic techniques have been used to improve postoperative pain management in VATS and promote the normalization of the concept of rapid recovery [23,24].
Updates on Enhanced Recovery after Surgery protocols for plastic surgery of the breast and future directions
Published in Baylor University Medical Center Proceedings, 2023
Nicholas F. Lombana, Ishan M. Mehta, Caiwei Zheng, Reuben A. Falola, Andrew M. Altman, Michel H. Saint-Cyr
Intercostal nerve blocks (Figure 5) are another commonly used nerve block used during breast reconstruction. The intercostal nerves of T2 through T7 are generally targeted, as these roughly correspond to the breast dermatome.34 The results surrounding the efficacy of intercostal nerve blocks are difficult to ascertain, as these blocks are often combined with PECS I/II blocks. In patients undergoing subpectoral implant-based reconstruction, authors saw a significant decrease in LOS, opioid consumption, and cost savings when 2 cc of 0.25% plain bupivacaine was administered per intercostal nerve.35 However, when comparing intercostal and PECS blocks to no block, one randomized controlled trial failed to find any difference with regards to opioid consumption and antiemetic use at 24 hours or LOS in patients undergoing immediate implant-based breast reconstruction.36
Related Knowledge Centers
- Peritoneum
- Somatic Nervous System
- Spinal Nerve
- Xiphoid Process
- Abdomen
- Thorax
- Sternum
- Upper Limb
- Ventral Ramus of Spinal Nerve
- Pulmonary Pleurae