Page | 432 ORI G I N AL ARTI C L E

Ultrasound‑guided rectus sheath block in children

with umbilical hernia: Case series
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Abdul Hamid Alsaeed, A B S T R A C T

Ahmed Thallaj,
Background: Umbilical hernia repair, a common day‑case surgery procedure in children,
Nancy Khalil, Nada AlMutaq,
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/24/2023

is associated with a significant postoperative pain. The most popular peripheral nerve
Ayman Aljazaeri1 blocks used in umbilical hernia repair are rectus sheath infiltration and caudal block.
The rectus sheath block may offer improved pain relief following umbilical hernia repair
Department of Anesthesia,
Pediatric Anaesthesia Division, with no undesired effects such as lower limb motor weakness or urinary retention seen
1
Department of Surgery, King Saud with caudal block which might delay discharge from the hospital. Ultrasound guidance
University, Riyadh, Saudi Arabia of peripheral nerve blocks has reduced the number of complications and improved the
quality of blocks.The aim of this case series is to assess the post rectus sheath block
pain relief in pediatric patients coming for umbilical surgery. Methods: Twenty two (22)
children (age range: 1.5-8 years) scheduled for umbilical hernia repair were included
in the study. Following the induction of general anesthesia, the ultrasonographic
anatomy of the umbilical region was studied with a 5‑16 MHz 50 mm linear probe. An
ultrasound‑guided posterior rectus sheath block of both rectus abdominis muscles (RMs)
was performed (total of 44 punctures). An in‑plain technique using Stimuplex A
insulated facet tip needle 22G 50mm. Surgical conditions, intraoperative hemodynamic
parameters, and postoperative analgesia by means of the modified CHEOPS scale were
evaluated. Results: ultrasonograghic visualization of the posterior sheath was possible
in all patients. The ultrasound guided rectus sheath blockade provided sufficient
analgesia in all children with no need for additional analgesia except for one patient
who postoperatively required morphine 0.1 mg/kg intravenously. There were no
complications. Conclusions: Ultrasound guidance enables performances of an effective
rectus sheath block for umbilical hernia. Use of the Stimuplex A insulated facet tip
Address for correspondence: needle 22G 50mm provides easy, less traumatic skin and rectus muscle penetration
Prof. Abdul Hamid Alsaeed, and satisfactory needle visualiza.
Department of Anesthesia,
Pediatric Anaesthesia Division, Key words: Anesthesia, analgesia, anesthetic techniques, peripheral nerve
King Saud University, Riyadh, block, postoperative, regional, rectus sheath block, surgery, umbilical hernia,
Saudi Arabia. ultrasonography, umbilical
E‑mail: [email protected]

was described in adults,[1] has been used for laparoscopic

INTRODUCTION
surgery in gynecology,[2] and is one of the currently used
Umbilical hernia repair is a common operation in pediatric techniques in pediatric umbilical surgery.[3] However, it may
surgery. It is carried out in children over 2 years old, be associated with complications such as retroperitoneal
usually under general anesthesia combined with a regional hematoma and possibility of peritoneal puncture.[4] The
block (caudal block). It is almost always done as a day case paraumbilical block[5] was described in 11 pediatric patients
procedure; a peripheral nerve block is usually the choice to avoid these complications and to improve the success
for postoperative pain relief. The rectus sheath block rate of the block.

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Recently, direct ultrasonographic visualization of the
Quick Response Code:
brachial plexus,[6] of the sciatic nerve in the popliteal
Website: fossa,[7] the ilioinguinal/iliohypogastric nerves,[8] and of
www.saudija.org rectus sheath[9] has been done successfully in children and
in infant.[10]
DOI:
10.4103/1658-354X.121079 The aim of this case series was to investigate the ultrasound
visualization of the anatomy in the umbilical region in

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 Alsaeed, et al.: Rectus sheath block in children
Page | 433
children and to evaluate postoperative pain relief following
rectus sheath block.

METHODS

Approval of the IRB ethical committee (King Khalid

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University Hospital, King Saud University, Saudi Arabia)

and informed consent from the parents were obtained in
all cases. Twenty‑two children, age range 1.5-8 years, ASA
physical status I or II, scheduled for paraumbilical hernia
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repair on an outpatient basis, were included in this case

series. None had a history of convulsion, neuromuscular
disease, or hematological disorders.

No premedication was given. Intraoperative monitoring Figure 1: Short‑axis sonographic view of the periumibilical region
included, ECG, pulse oximetry, non‑invasive blood shows: the rectus muscle surrounded by the rectus sheath (RS), internal
pressure, and end tidal carbon dioxide concentration. oblique muscle (I.O), external oblique muscle (E.O), transversus
abdominis muscle (T.A)

After general anesthesia was induced and venous access

established, fentanyl 2 mic/kg was given and an appropriate
size laryngeal mask airway was placed. Spontaneous
ventilation with 1 MAC sevoflurane in a mixture of 50%
air and oxygen was maintained in all cases throughout the
procedure.

The ultrasonographic anatomy of the umbilical region

was studied in each case, with 5‑16 MHz US linear
probe (Sonosite M TURBO). The probe positioned 1 cm
above the umbilicus, adjustments in depth and gain were
made in order to achieve the optimal sonographic view of
both rectus abdominis muscle (RMs), their sheaths, and
adjacent structures.

The sheath and lateral edge of the RM were localized, Figure 2: Needle tip and shaft visualization within the posterior rectus
peritoneum and the aponeurosis of ipsilateral transverse sheath fascial split by ultrasound during rectus sheath block and
injection of local anesthesia, the rectus sheath (RS), internal oblique
abdominis (TM), internal and external oblique muscles muscle (I.O), external oblique muscle (E.O), transversus abdominis
(EOM and IOM) were identified [Figure 1]. After muscle (T.A), local anesthesia (LA)
aseptic preparation of the puncture site, the ultrasound
probe was covered with sterile TEGADERM film (3M
Health Care St. Paul, MN, USA) and sterile ultrasound
gel was used (ULTRA/PHONIC PHARMCEUTICAL
INNOVATIONS, INC., NEW JERSEY, USA). The block
was performed a facet tip needle (Stimuplex A insulated
Needle 22G50 mm). The needle was introduced in the
long axis parallel to the ultrasound probe [Figure 2] to
reach the lateral border of the rectus muscle, and advanced
slowly and carefully until the tip of the needle was seen just
between the posterior aspect of the rectus abdominis and
its sheath [Figure 3]. A single injection of plain bupivacaine
0.25%, 0.25 ml/kg was injected each side under the
real‑time ultrasound control.

Surgery was then proceeded and hemodynamic parameters Figure 3: Needle position; in plane technique, the block needle is
were recorded. Intraoperatively, analgesia was evaluated and lateral to the ultrasound probe

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 Alsaeed, et al.: Rectus sheath block in children
Page | 434
fentanyl 1 mic/kg was planned to be administered if there the tendinous intersections of the rectus sheath are only
is an increasein heart rate or blood pressure of >10% or an anterior and do not extend through the thickness of the
increase in respiratory rate of more than 20% following the muscle, so a potential space would exist between the
skin incision or at any time during the procedure and was posterior aspect of its sheath.
defined as insufficient analgesia.
This potential space would allow dispersion of LA at several
At the end of the procedure, the laryngeal mask was levels, enabling an effect on several intercostal nerves, the
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removed and general anesthesia was discontinued. Children puncture was performed on each side of the abdomen, just
were taken to the post anesthesia care unit (PACU). above and lateral to the umbilicus, half‑to‑1 cm medial to
Postoperative analgesia was evaluated by a blind investigator the linea semilunaris. The block proved to be effective and
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using the modified CHEOPS pain scale[11] in the PACU safe both for umbilical and paraumbilical hernia repair.[3]
every 10 min until discharge. Children who scored 5
or more at any of the evaluated times were to be given One year later, in 1997, Courreges et al. described a new
morphine 0.1 mg/kg IV. In the surgical wards, trained technique to provide analgesia in 11 children undergoing
nurses recorded the time when the child first required the umbilical hernia repair: the paraumbilical block. The
additional paracetamol 20 mg/kg suppository as a authors stated that the course of the cutaneous branch
supplement analgesia. of the 10th intercostal nerve is variable, sometimes, it lies
between the rectus abdominis muscle and the posterior
wall of its sheath, but up to 30% of cases, the cutaneous
RESULTS branch of the 10th intercostal nerve could arise before the
rectus sheath and run above the anterior wall of the rectus
Demographic data were as follows: 14 females and 8 males,
sheath in the subcutaneous space.[5]
mean age 3.7 years (1.5‑8 years) and mean weight of
16 kg (range 10‑27 kg). Each received two punctures one Smith, et al. suggested that infiltration by LA in the middle
on each side of the umbilicus, a total of 44 punctures in of the rectus muscle, both above and below the anterior
22 patients. No increases in the heart rate or blood pressure wall of the sheath, would result in spread around the
were recorded intraoperatively, and no patient was given anterior cutaneous branches whatever the anatomical
additional fentanyl. Different Surgeons performed the variation.[2]
cases and assessed the surgical conditions as good in all
the patients. In recent years, high frequency ultrasonography is
of increasing interest in regional anesthesia, as direct
Peritoneum and the lateral edge of the rectus muscles were visualization of the anatomic structures allows optimal
easily identified in all the cases and the punctures were placement of the needle and thereby reduces the risk of
performed without complication. inadvertent interneural, intravascular, or adjacent structures
injury (peritoneum).
Only one child scored >5 in the modified CHEOPS Scale
and was given morphine 0.1 mg/kg intravenous in the PACU. In our case series, we described an ultrasound‑guided
The ward nurses reported no supplement of analgesia. All technique of the 10th intercostal nerve block using the facet
patients were discharged without complications. tip needle, which is considered as safety measure.

DISCUSSION Many anatomical variations of the point where the

intercostal nerve pierces the rectus sheath, in order to
The umbilical area is innervated by the right and left avoid these variations, the 10th intercostal nerve is better
10th intercostal nerves, anterior rami of the 10th spinal thoracic to be blocked before it pierces the sheath, i.e. between
roots. Each nerve passes behind the costal cartilage and runs the aponeurosis of the internal oblique muscle and the
between transversus abdominis and internal oblique muscles. transversus muscle; however in this case series, we were
not able to visualize the nerve due to several reasons.
At the level of the linea semilunaris, the nerve perforate Firstly, because of the small size of the intercostal nerve,
the rectus sheath posteriorly, innervate the rectus muscle, a higher ultrasound frequency probe is probably required
cross the muscle, and end as an anterior cutaneous branch to visualize such small nerves. Secondly, because of the
supplying the skin of the umbilical area.[12] course of the intercostal nerve before entering the rectus
muscle. It is difficult to differentiate the nerve from the
The rectus sheath block was first used in pediatric surgery aponeurosis by ultrasonography because the nerve runs
by Ferguson et al. in 1996,[3] the authors described that parallel to the muscular aponeurosis i.e., the nerve does

Vol. 7, Issue 4, October-December 2013 Saudi Journal of Anaesthesia

 Alsaeed, et al.: Rectus sheath block in children
Page | 435
not cross the aponeurosis and thus makes it difficult to between the loss of resistance and ultrasound guided
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4. Yuen PM, Ng PS. Retroperitoneal hematoma after rectus

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5. Courreges P, Poddevin F, Lecoutre D. Para‑umbilical block:
In this series, we used the in‑line puncture needle in a A new concept for regional anaesthesia in children. Paediatr
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because it is the only way to visualize the exact position 6. Marhofer P, Sitzwohl C, Greher M, Kapral S. Ultrasound
guidance for infraclavicular brachial plexus anaesthesia in
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Trautner H, Roewer N. Sonographic imaging of the sciatic
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8. Willschke H, Marhofer P, Bösenberg A, Johnston S, Wanzel O,
Cox SG, et al. Ultrasonography for ilioinguinal/iliohypogastric
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guidance enables performances of an effective rectus sheath Kettner SC, Wanzel O, et al. Ultrasonography –guided rectus
sheath block in pediatric anaesthesia‑ a new approach to an
block for umbilical hernia in the lateral edge of the rectus old technique. Br J Anaesth 2006;97:244‑49.
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22G 50 mm provides easy, less traumatic skin and rectus What suitability? (Letter). Paediatr Anaesth 1998;8:181‑82.
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by the ultrasound. The bilateral deposited of bupivacaine ketorolac tromethamine. Anesthesiology 1997;87:542‑6.
0.25% 0.5ml/kg within the space between the posterior 12. O’Brien MD. Peripheral nerves and plexuses. In: Martin B,
Bannister LH, Standing SM, editors. Section 8, Nervous
aspect of the rectus abdominis muscle and its sheath under System. In: William PL, editor. Gray’s Anatomy: The
real‑time ultrasonographic guidance provides sufficient Anatomical Basis of medicine and Surgery. 38th ed. Edinburgh:
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How to cite this article: Alsaeed AH, Thallaj A, Khalil N, AlMutaq

REFERENCES N, Aljazaeri A. Ultrasound-guided rectus sheath block in children
with umbilical hernia: Case series. Saudi J Anaesth 2013;7:432-5.
1. Dolan J, Lucie P, Geary T, Smith M, Kenny G. The rectus Source of Support: Nil, Conflict of Interest: None declared.
sheath block for laparoscopic surgery in adults: A comparison

Saudi Journal of Anaesthesia Vol. 7, Issue 4, October-December 2013