Rectus Sheath Block
Indications: Umbilical/Ventral hernias, laparoscopic surgery with umbilical port, laparotomy with vertical incision.
Positioning: Supine
Dose: Please see Local Anesthetic dosing page for recommended dosing guidelines.
Technique: Probe- Linear; Needle- In-plane
Single- Shot: The probe is oriented transversely just above the umbilicus. Sometimes correctly identifying the rectus muscle can be a challenge (think neonates or obesity). By placing following the rectus muscle across the midline, visualizing the linea alba and contralateral rectus muscle, one can verify that you are looking at the correct plane. After identification, place the widest portion of the muscle in the middle of the ultrasound screen. We typically perform medial to lateral using in-plane needle technique (as the needle path is more tangential to the peritoneum and perhaps less likely to injure). Advance the needle into the muscle so that the tip is resting on the posterior wall of the muscle. Hydrodissect to ensure correct position. The muscle should peel off its posterior fascial sheath.
Multi-level: if performing for a laparotomy and one needs more vertical spread, after identifying the rectus muscle, one can re- orient the probe parasagittally and inject in a cranial-caudal direction. By injecting paragittally with the aid of an ultrasound, one may get more vertical spread, as well being able to visualize the spread and place local where it is needed.
Catheters: We perform this in parasagittal plane, as we prefer the catheter to lie in the same plane as the incision. Think about where you want the catheter to lie. If the incision extends from the umbilicus to the xiphoid process, consider inserting the catheter below the level of the incision and threading it toward the xiphoid process. For vertical incisions below the umbilicus, consider inserting above the incision and threading toward the pubis. For full laparotomies, dealers choice. And don’t forget to tunnel the catheter laterally away the incision and dressings. It will be out of the way, more secure, and potentially less likely to leak.
Coverage: Ventral rami of the intercostal nerves supplying the anterior abdominal wall, typically T9-T11. No visceral coverage.
Potential Complications:
Intravascular injection or injury (causing a hemotoma)
Peritoneal puncture
Bleeding at needle insertion site
First described in 1899, the RSB was popularized in the 1990’s for outpatient umbilical hernia procedures. While earlier studies suggested no benefit when compared to local injection by the surgeons, this was before the routine use of ultrasound-guidance. One of the first randomized, prospective studies comparing ultrasound-guided RSB vs LAI was by Gurnaney et al. Their study found a statistically significant difference in the perioperative opioid medication consumption. A follow-up prospective, randomized, observer-blinded study by Dingeman et al compared the efficacy of USG-BRSB and LAI in open umbilical hernia repair. Patients with BRSB had higher percentage of patients with FACES scores of 0 and lower overall FACES scores in PACU. This was similar to a later study by Uchinami et al. Moreover, Dingeman et al found fewer doses of opioid and non-opioid were needed in BRSB cohort during their stay in the PACU, though this trend was not significantly significant. This trend was not continued at home, where both groups had similar FACES scores and pain medication usage. Of note, there was some non-compliance with the post-op analgesic study protocol, with over 41% receiving stronger analgesics than indicated.
Though there is heterogeneity in the sampled studies, a meta-analysis by Hamill et al suggests RSB effectively reduces pain after abdominal surgery in children. The blocks appear to reduce pain scores, reduce morphine requirements, and delay the time to rescue analgesia. This is similar to our data (Maloney et al), which also suggested a pre-incision RSB decreases opioid consumption, with lower pain scores and longer time to rescue analgesia.
Now that efficacy has been well established, one must now think about tailoring your approach to your specific patient. Visoiu et al showed incomplete spread with a single transverse injection when injecting at the level of the umbilicus. On average, they found that injecting 0.25mL/kg of solution they were able to visualize 6.9cm of spread in a cranial-caudal direction, which is roughly about 0.7cm/mL. The majority of spread was in above the umbilicus (3.9cm vs 1.5cm), though only around 45% spread to the subcostal margin. The implication is that one may need to tailor the injection site based on the expected incision, as well as the volume injected. Rather than injecting the entire volume in one location, you can easily visualize with the ultrasound where the local has not spread to and inject where you want more. I have done countless full laparotomies using multi-level rectus. Using 0.5mL/kg of volume for bilateral blocks, I almost never have any issues depositing local along the entirety of the rectus muscle (from pubis to xiphoid process).
All in all, the RSB remains a reliable, safe, easy to perform block for all peri-umbilical procedures, up to, and including, laparotomy.
Gurnaney, H.G., Maxwell, L.G., Kraemer, F.W., Goebel, T., Nance, M.L. and Ganesh, A., 2011. Prospective randomized observer-blinded study comparing the analgesic efficacy of ultrasound-guided rectus sheath block and local anaesthetic infiltration for umbilical hernia repair. British journal of anaesthesia, 107(5), pp.790-795.
Isaac LA, McEwen J, Hayes JA, Crawford MW. A pilot study of the rectus sheath block for pain control after umbilical hernia repair. Paediatr Anaesth. 2006 Apr;16(4):406-9
Visoiu, M., Hauber, J. and Scholz, S., 2019. Single injection ultrasound‐guided rectus sheath blocks for children: Distribution of injected anesthetic. Pediatric Anesthesia, 29(3), pp.280-285.
Malchow, R., Jaeger, L. and Lam, H., 2011. Rectus sheath catheters for continuous analgesia after laparotomy—without postoperative opioid use. Pain Medicine, 12(7), pp.1124-1129.
Dutton, T.J., McGrath, J.S. and Daugherty, M.O., 2014. Use of rectus sheath catheters for pain relief in patients undergoing major pelvic urological surgery. BJU international, 113(2), pp.246-253.
Godden, A.R., Marshall, M.J., Grice, A.S. and Daniels, I.R., 2013. Ultrasonography guided rectus sheath catheters versus epidural analgesia for open colorectal cancer surgery in a single centre. The Annals of The Royal College of Surgeons of England, 95(8), pp.591-594.
Dingeman, R.S., Barus, L.M., Chung, H.K., Clendenin, D.J., Lee, C.S., Tracy, S., Johnson, V.M., Dennett, K.V., Zurakowski, D. and Chen, C., 2013. Ultrasonography-guided bilateral rectus sheath block vs local anesthetic infiltration after pediatric umbilical hernia repair: a prospective randomized clinical trial. JAMA surgery, 148(8), pp.707-713.
Uchinami, Y., Sakuraya, F., Tanaka, N., Hoshino, K., Mikami, E., Ishikawa, T., Fujii, H., Ishikawa, T. and Morimoto, Y., 2017. Comparison of the analgesic efficacy of ultrasound‐guided rectus sheath block and local anesthetic infiltration for laparoscopic percutaneous extraperitoneal closure in children. Pediatric Anesthesia, 27(5), pp.516-523.
Hamill JK, Rahiri JL, Liley A, Hill AG. Rectus sheath and transversus abdominis plane blocks in children: a systematic review and meta-analysis of randomized trials. Paediatr Anaesth. 2016 Apr;26(4):363-71.
Maloney, C., Kallis, M., Abd El-Shafy, I., Lipskar, A.M., Hagen, J. and Kars, M., 2018. Ultrasound-guided bilateral rectus sheath block vs. conventional local analgesia in single port laparoscopic appendectomy for children with nonperforated appendicitis. Journal of pediatric surgery, 53(3), pp.431-436.
Hagen, J.G., Barnett, N., Kars, M.S., Padover, A. and Bunnell, A.M., 2019. Rectus sheath blocks in the extremes of body habitus. J Clin Anesth, 57.