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Go Home FasterRichard K. Baumgarten, MD, Grosse Pointe Farms, Mich.
A B. Braun 22G Epidural Needle used for a U/S guided II/IH block.
IN INGUINAL HERNIA REPAIR, past is prologue.
Despite its “state of the art” cachet, enthusiasm for
draped and fully anesthetized. The anesthesiologist can
laparoscopic hernia surgery has waned. Lap hernias take
perform II/IH block right after surgery in the recovery
longer, pose a higher risk of bladder and vascular
area in less than five minutes, provided the ultrasound
complications, and incur much higher supply costs. The
problem with open inguinal hernia repair, though, is thatit’s more painful. This hinders recovery and makes it
Ultrasound guidance is important because it improves
much harder for patients to void, significantly prolonging
block accuracy. Traditionally, practitioners performed
discharge. Patients typically say: “As soon as I try and
these blocks using the iliac crest as a landmark, with
press down, it hurts, and I have to stop.” The good
tactile feedback to advance the needle through the
news is that a new approach to pain management—
fascial planes. These “pops and plops” are a little
short-acting spinal anesthesia with an ilioinguinal
unreliable, and blocks are incomplete in 20 to 30
iliohypogastric(II/IH) nerve block performed in the
percent of patients. With ultrasound, the
recovery room—is an excellent way to manage the pain,
anesthesiologist can visualize the needle entering the
promote voiding, and help patients go home sooner.
fascial plane between the transverse abdominus andinternal oblique muscles. Even if one can’t see the
Here’s how it works. Before the procedure, the
small nerves directly, local anesthetic injected in this
anesthesiologist administers a short-acting spinal block.
Spinal anesthesia virtually eliminates the PONV seenwith general anesthesia. Lidocaine is an acceptable
By performing the block in recovery, after transferring
choice; but in many patients, it causes moderate to
monitoring responsibility to the recovery nurse, even
severe back and buttock pain lasting up to 24 hrs. This
the solo anesthesia provider doing consecutive cases
symptom constellation is called TNS. I prefer
can take advantage of II/IH blocks. This block also
preservative-free 2-chloroprocaine (2-CP) since it
works well for patients who prefer general anesthesia.
provides rapid, intense muscle relaxation with no TNS.
The practitioner can also perform these blocks pre-
My usual 2-CP dose is 35-50 mg for hernia surgery. It
operatively. In each scenario, the improved analgesia
lasts 30-60 minutes, and motor recovery is quick. To
will help patients recover more quickly, void faster, and
prevent or minimize spinal headache, I use small-gauge
go home sooner—keeping your patients happier and
References supplied upon request.
administers an ultrasound-guided II/IH nerve block.
Even though paravertebral block offers a perfect triad of
segmental anesthesia, muscle relaxation and prolonged
post-op analgesia, the II/IH block is more practical.
Paravertebral blocks have a “soak time” of 20 to 30
Medical Center in Lapeer, MI.
Email him at
minutes, and in our center, pre-op beds are at a
premium, hernia patients often arrive late, and surgeonsprefer to enter the room with the patient prepped,
The views expressed in this advertorial are those of the author only. Providers and clinicians are obligated to make their own determination of the appropriate
medical treatment for each of their patients.
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