The surgical rectus sheath block for post-operative analgesia: a modern approach to an established technique Emma J. Crosbie a,1, *, Nadine S. Massiah b,1 , Josephine Y. Achiampong b , Stuart Dolling c , Richard J. Slade b a Academic Unit of Obstetrics & Gynaecology, St Mary’s Hospital, Hathersage Road, Manchester M13 9WL, United Kingdom b Department of Obstetrics and Gynaecology, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom c Department of Anaesthetics, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, United Kingdom 1. Introduction There is an increasing demand for safe and effective regional anaesthetic techniques to deliver post-operative analgesia to patients undergoing abdominal surgery [1]. Intra-operative infiltration of local anaesthetic into the subcutaneous tissues around the wound is rarely sufficient to control post-operative pain [2], with patients requiring repeated boluses of opioid analgesia in the immediate and medium-term post-operative period and prolonged use of morphine based patient-controlled analgesia (PCA). Reliance on opioids to achieve adequate post- operative analgesia increases the risk of sedation, nausea, vomiting, constipation and paralytic ileus [3]. Epidurals provide extremely effective pain relief [4] and evidence suggests that they may reduce peri-operative morbidity, improve post-operative rehabilitation and reduce the incidence of chronic post-operative pain compared to opioid-based post- operative analgesia [5]. Unfortunately, not all patients are suitable for epidurals. Sepsis and coagulopathy are contraindications and the shift towards enhanced recovery programmes and reduced hospital stays has conspired to deny many eligible patients epidural-based post-operative analgesia. The rectus sheath block was first described by Schleich in 1899 when it was used to achieve peri-operative relaxation of the anterior abdominal wall [6]. More recently, the rectus sheath block has been used to achieve post-operative analgesia in a variety of clinical settings, including following laparoscopy [7,8], umbilical hernia repair [9,10], abdominoplasty [11], upper abdominal [12] and major gynaecological surgery [13]. The anterior abdominal wall has a multiple segmental nerve supply derived from the anterior divisions of the lower thoracic (T7–12) and first lumbar (L1) nerves [14,15]. These nerves pass European Journal of Obstetrics & Gynecology and Reproductive Biology 160 (2012) 196–200 A R T I C L E I N F O Article history: Received 23 June 2011 Received in revised form 6 October 2011 Accepted 27 October 2011 Keywords: Surgical rectus sheath block Post-operative analgesia Major gynaecological surgery Analgesic efficacy A B S T R A C T Objective: To describe the surgical rectus sheath block for post-operative pain relief following major gynaecological surgery. Technique: Local anaesthetic (20 ml 0.25% bupivacaine bilaterally) is administered under direct vision to the rectus sheath space at the time of closure of the anterior abdominal wall. Study design: We conducted a retrospective case note review of 98 consecutive patients undergoing major gynaecological surgery for benign or malignant disease who received either standard subcutaneous infiltration of the wound with local anaesthetic (LA, n = 51) or the surgical rectus sheath block (n = 47) for post-operative pain relief. Main outcome measures: (1) Pain scores on waking, (2) duration of morphine-based patient controlled analgesia (PCA), (3) quantity of morphine used during the first 48 post-operative hours and (4) length of post-operative stay. Results: The groups were similar in age, the range of procedures performed and the type of pathology observed. Patients who received the surgical rectus sheath block had lower pain scores on waking [0 (0– 1) vs. 2 (1–3), p < 0.001], required less morphine post-operatively [12 mg (9–26) vs. 36 mg (30–48), p < 0.001], had their PCAs discontinued earlier [24 h (18–34) vs. 37 h (28–48), p < 0.001] and went home earlier [4 days (3–4) vs. 5 days post-op (4–8), p < 0.001] [median (interquartile range)] than patients receiving standard subcutaneous local anaesthetic into the wound. Conclusions: The surgical rectus sheath block appears to provide effective post-operative analgesia for patients undergoing major gynaecological surgery. A randomised controlled clinical trial is required to assess its efficacy further. ß 2011 Elsevier Ireland Ltd. All rights reserved. * Corresponding author. Tel.: +44 0161 701 6912. E-mail address: emma.crosbie@manchester.ac.uk (E.J. Crosbie). 1 These authors contributed equally to this work. Contents lists available at SciVerse ScienceDirect European Journal of Obstetrics & Gynecology and Reproductive Biology jou r nal h o mep ag e: w ww .elsevier .co m /loc ate/ejo g rb 0301-2115/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2011.10.015