Background

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Optimal pain control after major surgery is paramount in preventing postoperative complications. Recent adoption of enhanced recovery after surgery protocols has highlighted the critical importance of analgesia protocols, ensuring rapid patient recovery through early mobilisation.^1,2 Traditional epidural analgesia can impair mobilisation and, importantly, can impact on the postoperative ‘fluid shift’ from the vasodilatory effect. In major hepatopancreatobiliary surgeries using a reverse-L incision, analgesia via surgically placed transversus abdominis plane and rectus sheath catheters represents an excellent alternative, without ‘fluid-shift’ effects.^3,4

Technique

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We describe the technique for a reverse-L incision using widely available equipment, illustrated with a step-by-step video. It is an adaptation of a technique reported by Behman et al for rooftop incisions.⁵

First, we identify the transversus abdominis plane layer, above which the nerves run, followed by creation of a pocket by dissecting the natural plane between transversus abdominis and internal oblique muscles (Fig 1). Next, we create a pocket below the posterior rectus sheath, followed by closure of the posterior rectus sheath and tranversus abdominis layer. An epidural catheter is then inserted into each pocket using a bent 16-G epidural needle. This is followed by closure of the anterior fascia. The catheters are secured by single skin tunnelling and dressing to avoid dislodgement.

Figure 1 Creation of a pocket by dissecting the natural plane between transversus abdominis and internal oblique muscles. (a) As seen in reverse-L incision. (b) Transverse abdominis plane. (c) Posterior rectus sheath.

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Video link:

https://publishing.rcseng.ac.uk/journal/video?doi=10.1308%2Fvideo.2019.8.2&videoTaxonomy=TECH

Discussion

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Transversus abdominis plane and rectus sheath catheter placement is a robust technique for pain management. This report details an easy approach with step-wise illustration, without a need for new equipment for its placement. The procedure will add 30 minutes to the closure time.