USG guided peripheral nerve block in surgery for hernia

Nader Abbas Malvia, R. Nagesh, Srivasta

Department of Anaesthesia and Intensive care, Kauvery Hospital, Electronic City, Bengaluru

Background

Hernia is defined as “Protrusion of any viscus or part of the viscus through an abnormal opening in the walls of its containing cavity.” A wide variety of anaesthetic techniques have been used for inguinal hernia repair such as spinal, epidural, general anaesthesia and local anaesthesia (Nerve block).

Case Presentation

A 72-years-aged male patient was admitted to the hospital for Right Inguinal Hernia surgery. Patient was on medications for ischemic heart disease, for about 12 years (Tab. Cordarone 200 mg, Tab. Dytor 10 mg, Tab. Ecosprin AV 75 mg, Tab. Cardivas 6.25 mg), had history of permanent pacemaker (PPI) insertion 2 years back for brady arrhythmias, symptoms suggestive of paroxysmal nocturnal dyspnoea and history of repeated hospitalizations for past one year for heart failure. He had undergone Prostate Artery Embolization for BPH two years back.

Patient was evaluated, blood investigations, ECG and 2D Echo were done. 2D Echo showed EF: 20-25%, poor LV Systolic dysfunction, grossly dilated LV, dilated LA, RA, moderate MR and RWMA +; cardiology opinion was sought.

He was taken up for surgery. Preop optimization was done and patient was started on Inj. Lasix; Tab. Dytor was withheld. Patient was shifted to ICU and started on maintenance dose of Inj. Dobutamine one day prior to surgery. Patient’s attenders were counselled regarding the clinical condition of the patient and informed high-risk consent was taken.

Surgery was planned under USG guided Right sided Ilioinguinal and Iliohypogastric nerve block and genital branch of genitofemoral nerve block.

Pre-op instruction of NPO and pre-op medications (Inj. Ondensetron 4 mg IV and Inj. Pantaprazole 40 mg IV) were given 30 min before surgery.

Patient was shifted to OT, standard monitors were connected, arterial line was secured.

Under strict aseptic precautions parts were painted and draped. Under USG guidance Right sided Ilioinguinal and Iliohypogastric nerve block and genital branch of genitofemural nerve block was given. 5 ml of Inj. 2% Lignocane with Adrenaline (1:200000) + 5 ml of 0.5% Inj. Bupivacaine given. Adequate surgical anaesthesia was achieved.

USG guided block was chosen for surgery in this patient because of very poor cardiac reserve. Giving gsnerae or spinal anaesthesia would have increased the probability of morbidity and mortality.

Conclusion

Expertise in USG guided peripheral nerve blocks is an essential armor for a modern-day anesthesiologist. especially for high-risk cases.

Nader Abbas Malvia

Consultant

USG guided peripheral nerve block in surgery for hernia