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Abstract
Background and Aims A 59-year-old male patient affected by amyothrophic lateral sclerosis (ALS) was scheduled for open gastrostomy. He was tetraplegic with preserved sensitivity, breathing spontaneously and supported by NIV for 6 hours/night. The purpose of this report is to show the efficacy of the external oblique intercostal block in upper abdominal wall surgery.
Methods We placed a high-frequency probe (6–12MHz) in sagittal orientation along the mammillary line at the level of the 6th rib with the patient in supine position 30 minutes before surgery. A 21G x 80mm needle (Pajunk Sonoplex) was advanced in plane in cranio-caudal direction. We injected ropivacaine 15 ml 0.5% bilaterally opening the fascial plane between the intercostal and external oblique muscles, aiming for the anterior and lateral cutaneous branches of intercostal nerves T6 to T9/10.
Results During 80-minute surgery, the patient maintained spontaneous ventilation with supplemental oxygen (3 l/min). Comfort was provided by light sedation with propofol in TCI 1.0–1.4 µg/ml (Schnider) and staggered administration of fentanyl 150 µg. He remained hemodynamically stable and pain-free in the intra and immediate postoperative period with 1g IV acetaminophen 8-hourly and no rescue analgesia.
Conclusions The external oblique intercostal block is a recent fascial plane block for multimodal analgesia in the context of upper abdominal surgery and may be more effective than subcostal TAP block for the upper lateral abdominal wall. It is a safe technique due to the easy sonoanatomy and bony backstop and could be particularly valuable in frail patients or when general anesthesia and myorelaxation may be harmful.
