Open Journal of Anesthesiology, 2013, 3, 298-300 http://dx.doi.org/10.4236/ojanes.2013.36065 Published Online August 2013 (http://www.scirp.org/journal/ojanes) New Approach of Ultrasound-Guided Genitofemoral Nerve Block in Addition to Ilioinguinal/Iliohypogastric Nerve Block for Surgical Anesthesia in Two High Risk Patients: Case Report Achir A. Al-Alami, Mahmoud S. Alameddine, Mohammed J. Orompurath Anesthesia Department, International Medical Center, Jeddah, KSA. Email: achiralami@gmail.com Received April 20 th , 2013; revised May 20 th , 2013; accepted June 15 th , 2013 Copyright © 2013 Achir A. Al-Alami et al. This is an open access article distributed under the Creative Commons Attribution Li- cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT We report two high risk patients undergoing inguinal herniorraphy and testicular biopsy under ultrasound-guided ilio- inguinal/iliohypogastric and genitofemoral nerve blocks. The addition of the genitofemoral nerve block may enhance the ilioinguinal/iliohypogastric block to achieve complete anesthesia and thus avoid general and neuraxial anesthesia related hypotension that may be detrimental in patients with low cardiac reserve. Keywords: Nerve Block; Ultrasound; Genitofemoral Nerve; Ilioinguinal Nerve; Iliohypogastric Nerve; Testicle Biopsy; Inguinal Hernia 1. Introduction The high incidence of chronic post-surgical pain associ- ated with inguinal hernia repair is well documented [1,2]. The technical difficulty in identifying and selectively blocking the nerves concerned makes the subject to be studied in detail. In particular ilioinguinal/iliohypogas- tric (II/IH) nerve block has widely been used for inguinal hernia repair. The sensory innervations from genitofe- moral (GF) nerve to the inguinal region may provide in- sufficient analgesia by this technique for intra- and post- operative pain management. Therefore, an addition of ge- nitofermoral nerve block that improves the quality of analgesia is proposed. 2. Case Report 2.1. Case 1 A 76-year-old gentleman with past medical history of end-stage renal disease on dialysis, systemic hyperten- sion, severe pulmonary hypertension and interstitial lung disease was scheduled to undergo a left open inguinal herniorraphy with mesh. His body weight was 50 kg and the preoperative coagulation profile was within normal limit except platelet count of 80,000. Ultrasound-guided II/IH and GF nerve blocks were planned for anesthesia. Patient was placed in supine position, with standard American society of Anesthesiology (ASA) monitors in place. Face mask oxygen was supplemented at 5 lt/min. Intravenous (i.v) sedation was given using propofol: ketamine mixture in the ratio 4:1 infused at 5 ml/hr. The local anesthetic (LA) mixture constituted of 2% lidocaine with 0.5% bupivacaine mixed at ratio 1:1 with the addi- tion of epinephrine 1/400,000. The left inguinal area was prepped with 70% alcohol and iodine. A linear probe with 10 Hz frequency with depth of 2.5 cm was used for scanning (Ultrasonix, Sonix, Richmond, Canada). For II/IH block, the ultrasound probe covered with sterile sheath was placed at the anterior superior iliac spine (ASIS) in oblique fashion at the line joining the umbilicus and the ASIS. The two muscles, the internal oblique and transverses abdominis were in view (Figure 1). A 22 G spinal Quincke needle (Madrid, Spain) was introduced in-plane; hydro-dissection technique with nor- mal saline was used to localize the needle tip. After negative aspiration 20 ml of the LA was deposited be- tween transverse abdominis and internal oblique; and between internal and external oblique muscles. For GF block, the ultrasound probe was placed parallel Copyright © 2013 SciRes. OJAnes