Vertical and Midline Surgery
Eric Haas, MD, Chief of the Division of Colon and Rectal Surgery at Houston Methodist Hospital and Program Director of the Minimally Invasive Colorectal Surgery Fellowship Program at the University of Texas at Houston demonstrates local wound infiltration.
This case involves a 72-year-old male with transverse colon cancer undergoing elective segmental resection through a single-incision laparoscopic port. The technique shown here at the port site is in standard use in all patients. There is a vertical umbilical incision made in this elderly, obese patient. Our multimodal perioperative standard treatments include: gabapentin and celecoxib preoperatively, dexamethasone and acetaminophen at induction, post induction pre-incision TAP infiltration, as well as nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and antiemetics before a patient wakes up. These regimens lower postoperative pain, opioid needs, and related complications. They also reduce risk of residual paralysis in the postanesthesia care unit (PACU) after surgery. We use scheduled non-opioids before, during, and after surgery to reduce the pain threshold and maintain baseline pain levels at <4 out of 10.
Clinical Infiltration Pearls from Video Segment
– Injections are performed in a fanning fashion with the injectate being pushed in upon withdrawal of the needle
– Needle is moved at an angle to the right and to the left; the needle is then advanced by 1 cm in each direction
– Infiltration begins in the peritoneum followed by the fascia; then the suture is closed and the dermal or subdermal layers are infiltrated
– It is best to move in small areas because the consistency of the liposomal bupivacaine is more viscous than regular bupivacaine and it does not dissipate as well