1. 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

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

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

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

6. 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.

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

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

12. 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

13. Create a wall of local between iliac crest and umbilicus

14. 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

16. Ultrasound guided
Peritoneum

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

18. 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

19. 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

20. Local
Subcostal

21. 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

22. 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

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

24. Any Alternate

25. Ilio inguinal type of TAP
Volume upto 25 ml

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

27. Thank you all