The mission of the Surgical Pain Consortium (SPC) is to raise awareness and promote best practices for the improvement of surgical pain management.
The SPC consists of an evolving multidisciplinary advisory group comprised of anesthesiologists, general and specialty surgeons, nurses, pharmacists, hospital administrators, regulatory compliance and patient safety experts, whose mission is to develop and disseminate optimized multimodal pain management tools, and to raise awareness regarding best practices for improving surgical pain management procedures currently used by US and global providers, patients, and payers.
For more information, please see their website http://surgicalpainconsortium.org/.
Surgical Site Infiltration For Abdominal Surgery: A Novel Neuroanatomical-Based Approach
Girish P. Joshi, MBBS, MD, FFARCSI + Working Group
Authors: Girish P. Joshi, MBBS, MD, FFARCSI
Affiliations: University of Texas Southwestern Medical Center, Dallas, Texas
Girish P. Joshi, MBBS, MD, FFARCSI
Professor of Anesthesiology and Pain Management
University of Texas Southwestern Medical Center
5323 Harry Hines Blvd
Dallas, Texas 75390
Phone: (214) 590-7259
Short Title: Surgical Site Infiltration Abdominal Surgery
Key Words: Pain, Postoperative, Surgical Site Infiltration, Neuroanatomy
Disclosure: Girish P. Joshi, MBBS, MD, FFARCSI, has received honoraria from Pacira Pharmaceuticals, Mallinkrodt Pharmaceuticals, and Baxter Inc.
Enhanced recovery after surgery (ERAS), also known as fast track or accelerated surgery or enhanced recovery protocols (ERP), involves implementation of evidence-based multimodal procedure-specific perioperative care pathways [1-3]. Several systematic reviews and meta-analyses have shown that implementation of ERAS protocols in patients undergoing abdominal surgery improve perioperative outcomes (e.g., bowel function), allow early ambulation, and reduce hospital length of stay as well as improve patient satisfaction and reduce healthcare costs [1-3]. One of the major elements of a successful ERAS program is provision of optimal postoperative analgesia to facilitate ambulation and rehabilitation therapy .
An optimal multimodal analgesia technique would include the use of non-opioid analgesics with different mechanisms of action with the aim of reducing the need for opioids . Reduction in opioid requirements should reduce opioid-related adverse events (ORAE), which have been shown to increase perioperative morbidity and delay ambulation and rehabilitation therapy . An ideal multimodal analgesic technique would include local/regional analgesic techniques (i.e., neuraxial blocks [epidural and paravertebral analgesia], field blocks [e.g., transversus abdominis plane (TAP) blocks and rectus sheath block], and surgical site infiltration) combined with acetaminophen and a non-steroidal anti-inflammatory drug (NSAID) or cyclooxygenase (COX)-2 selective inhibitor [4-6]. In addition, analgesic adjuncts such as dexamethasone (single intraoperative dose) and gabapentinoids (i.e., gabapentin and pregabalin) provide further benefit [4, 7].
This article presents a novel approach to surgical site infiltration techniques for abdominal surgical procedures based upon neuroanatomy.
Origin of Pain in Abdominal Surgery
The origin of pain from abdominal surgery is multifactorial, including a parietal (or somatic) component originating from the surgical incision and a visceral component originating from the peritoneum and manipulation of the intra-abdominal structures. The somatic innervation of the anterior abdominal wall arises from the thoracolumbar spinal nerves (i.e., T6 to L1). A recent cadaveric study assessing the course of anterior abdominal wall nerves found that there is extensive branching and communications between the abdominal nerves . The communications occur at several sites including the intercostal plexus, anterolateral large branch communication, the TAP plexus that lies between the internal oblique and the transversus abdominis muscles (T9 to L1 segmental nerves adjacent to the deep circumflex iliac artery), and the rectus sheath plexus that comprises all the segmental nerves (i.e., T6 to L1) adjacent to the deep inferior epigastric artery. In most cases these nerves also pierce the posterior surface of the rectus abdominis muscle (Figure). The muscular and cutaneous branches of these segmental nerves enter the muscle and finally terminate in the skin. The skin above the umbilicus is supplied by the cutaneous nerves derived from T6 to T9, the area around the umbilicus is innervated by T10, and the skin below the umbilicus is derived from T11, T12, and L1.
It is now evident that the peritoneum is a metabolically active organ, and responds to surgical insult by manifesting a local and systemic immunologic and inflammatory response [9-11]. The peritoneum consists of ‘silent nociceptors’ that are activated by surgical injury and intraperitoneal inflammation, and contribute to visceral pain . The neuro-immuno-humoral pain pathways involved in abdominal surgery include somatic nerves and autonomic nerves such as the afferent fibers of the abdominal vagus nerve . Parasympathetic activation has been shown to influence perioperative outcome [13, 14].
Optimal Surgical Site Infiltration Technique For Abdominal Wall
Based upon the neuroanatomy described above, an optimal surgical site infiltration technique for the abdominal wall would consist of administration of local anesthetic into the peritoneal, musculofascial, and subdermal tissue planes. Thus, upon completion of the surgical procedure but before closure of the surgical wound, the first tissue plane that should be infiltrated is the peritoneum. The importance of peritoneal component to abdominal pain can be explained by the evidence that intraperitoneal local anesthetic nebulization, which distributes local anesthetic throughout the peritoneal cavity provides excellent pain relief . Similarly, intraperitoneal instillation of local anesthetic provides excellent pain relief [16, 17]. Furthermore, preperitoneal local anesthetic infusion has been shown to provide excellent pain relief after abdominal surgery [18, 19]. Several studies have reported that peritoneal closure increases postoperative pain, suggesting that the trauma from peritoneal closure induces pain [20, 21], probably similar to that caused by peritoneal incision. The next tissue plane that should be infiltrated, after the closure of the peritoneum, is the musculofascial plane, as the abdominal nerves run through it. Infiltration of the fascial plane with or without local anesthetic infusion through catheters has been reported to improve pain relief, reduce opioid requirements, and improve postoperative outcome [22-24]. Finally, the subdermal tissue should be infiltrated so as block the peripheral nerve endings [25, 26]. Of note, infiltration of the subdermal tissue alone has produced variable results [27, 28].
A recent study in women undergoing open abdominal hysterectomy through a horizontal incision found that surgical site infiltration which included peritoneal, musculofascial, and subdermal planes provide superior pain relief compared with bilateral TAP blocks . An infiltration technique for hernia surgery would involve local anesthetic infiltration around the neck of hernia sack (i.e., peritoneal tissue), musculofascial, and subdermal layers .
Optimal Infiltration Technique For Open Abdominal Wall Reconstruction Surgery
Infiltration of local anesthetics for abdominal wall reconstruction (AWR) using the transversus abdominus release (TAR) approach also includes infiltration of the peritoneal, musculofascial and subdermal tissue planes. The first injection plane occurs after the retrorectus dissection reveals the neurovascular bundles at the lateral boarder of the posterior rectus sheath as they course through the transversus abdominus anteriorly to the anterior rectus fascia. The injection through the posterior rectus sheath and into the transversus abdominus muscluofascial plane and preperitoneal space creates a hydrodissection plane, which often makes separation of the transversus abdominus from the peritoneum much easier. Optionally, after the mesh has been attached to the cut lateral transversus abdominus musculofascial plane bilaterally, another musculofascial plane infiltration can be performed into the cut transversus abdominus at the area of mesh fixation bilaterally. At the time of incision closure, a subdermal infiltration before skin closure is completed. Because of the large surface area required to perform infiltration for AWR, dilution of the chosen anesthetic may be required.
Optimal Infiltration Technique For Laparoscopic Ventral Hernia Repair Surgery
The local anesthetic solutions that can be used for postoperative pain control include bupivacaine (maximum dose ~150 mg), ropivacaine (maximum dose ~300 mg), and liposomal bupivacaine (maximum dose = 266 mg). The duration of analgesia achieved with bupivacaine HCL and ropivacaine is typically 8-12 h [28, 29]. Liposomal bupivacaine (Exparel®, Pacira Pharmaceuticals, Inc., San Diego, CA, USA) is a sustained-release local anesthetic, approved for administration into the surgical site [31-33]. The maximum recommended dose of liposomal bupivacaine is 266 mg (20 mL). It can be diluted with preservative-free normal (0.9%) sterile saline up to 300 mL. Liposomal bupivacaine should not be admixed with lidocaine, as it displaces bupivacaine from the liposomal formulation, which can lead to bupivacaine toxicity .
The concerns with local/regional analgesia include the potential for local anesthetic systemic toxicity, wound infection and delayed healing, and myotoxicity. The likelihood and intensity of a potential systemic local analgesic toxicity depends on the cumulative local analgesic dosages administered, the vascularity of the injection site, and use of additives such as epinephrine .
When performing wound infiltration it is necessary to follow some basic clinical practices. It is best to infiltrate with a 22 gauge, 1.5-inch needle. It is important to ensure that all layers of the surgical incision are infiltrated in a controlled and meticulous manner and that the medication is injected within the tissue planes under direct visualization (see above). When direct visualization is not possible, the location of the needle tip may best be appreciated by the sensation of a “pop” or “feel” as the needle passes through the different layers of the abdominal wall. The needle is inserted approximately 0.5-1 cm into the tissue plane (e.g., peritoneal or musculofascial plane) and local anesthetic solution is injected while slowly withdrawing the needle, which should reduce the risk of intravascular injection. Proper infiltration technique involves using a continuous motion fanning technique (commonly referred to as a “moving needle technique”).
The volume of local anesthetic would depend on the size of the incision. The typical volume for surgical site infiltration would be 0.5-1 mL every 1-1.5 cm of surgical incision per layer. Thus, for a horizontal incision for open abdominal hysterectomy, which is typically 12-15 cm long, the total volume could be 60 mL, with 20 mL injected into the peritoneal plane, 20 mL injected in the musculofascial plane, and 20 mL injected in the subdermal plane. For AWR using the TAR approach the total volume of the injection is 100-150 mL because of larger areas of dissection.
The recommended injection solution for liposomal bupivacaine is 20 mL (266 mg) combined with 30 mL, 0.25% bupivacaine HCl (75 mg) with epinephrine and saline to achieve the total volume as described above. Although liposomal bupivacaine has 3% bupivacaine HCl, dilution with saline would reduce this amount and therefore, addition of bupivacaine HCl to liposomal bupivacaine allows for a faster onset and improved pain relief in the immediate postoperative period (i.e., post anesthesia care unit).
The benefits of optimal pain management are well recognized. Nevertheless, treatment of postoperative pain continues to be a major challenge and inadequate postoperative pain relief remains disturbingly common. One of the reasons for suboptimal pain management may be related to inadequate or improper application of available analgesic therapies. An optimal analgesic technique would block all noxious stimuli that result from surgical insult including parietal and visceral components.
Previous studies evaluating analgesic efficacy of surgical site infiltration analgesia have reported variable degrees of success most likely due to inadequate or improper technique (i.e., indiscriminate subcutaneous injection after the closure of the wound) [27, 28]. Infiltration techniques vary from procedure to procedure, requiring knowledge of each surgical site and its anatomy to produce optimal results. Attention to proper infiltration technique is essential to attain the maximum benefits. Systematic and extensive placement of local analgesic into peritoneal, musculofascial, and subdermal tissues, where pain foci originate, is critical. Of note, such a meticulous surgical site infiltration in the various tissue planes requires the use of larger volumes of local anesthetic solution.
It is important to understand that it is necessary to combine surgical site infiltration analgesia with other non-opioid analgesics leaving opioids available for rescue . Optimal multimodal pain therapy should be initiated in the preoperative period with identification of patients at risk of greater pain intensity. Patient counseling and expectation management should improve pain relief and patient satisfaction. Finally, it should be noted that to achieve shorter hospital lengths of stay, it is necessary to use a comprehensive patient care pathway that includes optimization and standardization of the preoperative, intraoperative and postoperative care components.
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