1. A CASE OF OBTURATOR HERNIA AND HIGH VOLUME ILIOINGUNINAL- ILIOHYPOGASTRIC NERVE BLOCK
1.Ehime University Graduate School of Medicine, Department of Anesthesia and Perioperative Medicine　Toon, Ehime, Japan
2.Ehime Prefectural Imabari Hospital, Imabari, Ehime,Japan
Aisa Watanabe1, Kenichi Takechi2, Toshihiro Yorozuya1
Introduction
Figures
An obturator hernia (OH) is a rare condition with high rates of morbidity and mortality in elderly females. 1)
We experienced a case of OH on which we could not perform spinal anesthesia and instead we successfully managed it with an ultrasound guided,high volume ilioiguninal-iliohypogastric nerve block. SC EO
SC: Subcutaneous tissue
EO: External oblique muscle
IO: Internal oblique muscle
TA: Transversus abdominis
muscle
TF: Transversalis fascia
IC: Iliac crest
AC: Abdominal cavity
LA: Local anesthetics IO LA TA TF IC
Needle
Case report AC
Case:
A 99-year-old female (height 143 cm, weight 44 kg)
Comorbidities: Congestive heart failure and mild dementia.
Anesthesia Plan
Plan A: Spinal anesthesia (could not perform)
Because of her old age and severe comorbidities, we thought that general anesthesia should be avoided.
Plan B: An ultrasound guided, ilioiguninal- iliohypogastric nerve block with dexmedetomidine sedation.
Anesthesia Course
Iliohypogastric nerve block: 0.5% ropivacaine 5ml (Fig.2)
Ilioiguninal nerve block: 0.5% ropivacaine 20ml(Fig.3)
The spreading of the local anesthetics over the transversalis was confirmed by the ultrasound image.(Fig.4)
Ten minutes after the block, cold hypoesthesia in the ilioiguninal- iliohypogastric nerve area was confirmed.
Dexmedetomidine (loading dose 4μg/kg/hr, 15min and maintenance dose μg/kg/hr) was injected during the operation.
BIS score was maintained at during the operation.
Very small body movements were observed during surgery but they did not disturb the surgical procedure.
Clear liquid that was thought to the local anesthetics was observed in the surgical site over the transversalis fascia.
Total operation time was 83 minutes and the patient does not recall any memories from the surgery.
Fig.1: Pre block
Fig.2: Iliohypogastric nerve block EO
Ilioiguninal &
liohypogastric
nerves IO EO
Rectus
muscle TF IO TF TA IC
Needle LA
Femoral
nerve TA
Psoas
major
muscle
Gluteus
muscles
Iliac
muscle
Fig.3: Ilioiguninal nerve block
Fig.4: post block
Figure from Ref 2
Discussion
Generally, OH is often associated with old age and comorbidities and general anesthesia should be avoided.1)
An ultrasound guided, ilioinguninal-iliohypogastric nerve block is usually performed with a lower volume ( ml/Kg) for open during ilioinguinal hernia repair.
However, because of its deep surgical site, an ilioinguninal-iliohypogastric nerve block is usually considered inadequate as the sole anesthesia for OH repair.
On the other hand, in cadaveric study, local anesthetic is spread heavily on the transversalis fascia after being injected between the internal oblique muscle and transversus abdominis.2)
In our case, high volume ropivacaine spread heavily over the transversalis fascia and was effective as the sole anesthesia for OH repair.
References
1) Ulus Travma Acil Cerrahi Derg 2016; 22: 297–300, ) J Korean Surg Soc 2011; 81: