MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics- Hernia block Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics- PhD ( physiology), IDRA

When to think about it ?? Spinal Epidural General anesthesia Is Contraindicated As out patients

When it is difficult to perform ? Obese patients – USG to our rescue ?? Large hernias Femoral hernias – (usually obstructed) Irreducible

Relevant anatomy Ilio hypogastric Ilio inguinal Subcostal T11 Genito femoral Sympathetic Opposite side

The subcostal nerve (T12) and the ilioinguinal and ilio hypogastric nerves (derived from L1) innervate the inguinal area. The ilioinguinal and iliohypogastric nerves pass over the anterior superior iliac spine (ASIS) and, after piercing the internal oblique aponeurosis about 2 to 3 cm medial to the ASIS, travel between the internal and external oblique aponeurosis. Here they lie in close proximity to the spermatic cord and accompany the cord structures to the genitals.

Spermatic cord – GF and sympathetics subcostal Genital branch Spermatic cord – GF and sympathetics

Patient position – supine Anesthesiologist by the side Ultrasound if used – opposite side

ILIH blocks 2 cm medial and inferior to ASIS vertical Two pops Or hit the bone to withdraw Fan out 10 ml of LA Same point medial and above towards the umbilicus drop 8 ml above the transversus

Create a wall of local between iliac crest and umbilicus

Genito femoral Mid inguinal point dip vertical 2 cm Drop 5 ml Pubic symphysis To go laterally and – above and below 5 ml Opposite side Ask surgeon during cord manipulation- drop LA

Ultrasound guided Peritoneum

Separate and give local Inplane needle Just near iliac crest Separate and give local Medial - beware of DCIA

Hyperechoic two nerves Sometimes as a single nerve Trace it both sides – not fascia Soak the nerves mostly 5 ml is enough Spread some local anesthestic in the subcutaneous area for subcostal nerve block Sometimes the external oblique may not be seen confirm from below peritoneum Dose in pediatrics – 0.1 ml / kg

Pharmacology Do we need relaxation of muscles ?? NO 0.1 ml or 0.2 ml / kg is also ok 0.25 % bupivacaine 1 % lignocaine is OK 0.3 mic / kg of dexmed has been added to prolong analgesia Steroids added – for pain procedures

Local Subcostal

Complications - rare Undesired femoral nerve block can occasionally (1 out of 9) occur due to the spread of the local anesthetic to the inguinal ligament. Bowel injury Vascular injury

Genito femoral nerve Some times its difficult to block Ask surgeons to give three ml of local when they open the canal and see the cord Spermatic cord local

Systemic sedation Ilio inguinal Ilio hypogastric Subcostal Genito femoral Pending ?? Opposite side Same as classical Systemic sedation

Any Alternate

Ilio inguinal type of TAP Volume upto 25 ml

Summary Indications Contraindications Anatomy of the area & Nerves to be blocked Classical techniques USG guided Alternatives

Thank you all