Ultrasound-guided rectus sheath block for anterior cutaneous nerve entrapment sy

lNTRODUCTlON

Laparoscopic surgery is generally less invasive than open surgery.Recently,laparoscopic repair of perforated peptic gastroduodenal ulcers has become more commonly performed.Advantages of the laparoscopic repair of a perforated peptic ulcer are less postoperative pain[1,2],a lower rate of surgical site infection[2],and shorter postoperative hospital stay[1].

Even though laparoscopic surgery is less invasive,chronic abdominal wall pain after laparoscopic surgery can complicate postoperative recovery and be debilitating to the patient[3].Chronic abdominal wall pain is thought to be caused either by a viscus and/or the abdominal wall.The differential diagnosis depends on the origin of the pain.Anterior cutaneous nerve entrapment syndrome(ACNES)is defined as abdominal pain due to entrapped intercostal nerves[4].We successfully treated a patient with ACNES,which developed after laparoscopic repair of a perforated gastroduodenal ulcer,using ultrasound-guided rectus sheath block.Written informed consent was obtained from the patient for the publication.

CASE PRESENTATlON

Chief complaints

A 44-year-old man underwent emergency laparoscopic repair of a perforated gastroduodenal ulcer.Laparoscopic repair was performed successfully,and he was discharged without complications on postoperative day nine.One month later,he experienced severe pain in the left upper abdomen.

In the course of a great many journeys to the forest he carried away many rich stuffs and much fine linen36, and set up a shop opposite that of Ali Baba s son

History of present illness

The pain was sharp,with a stabbing sensation two or three times per day without obvious cause and lasted for at least two hours.The pain disturbed his work and degraded his quality of life.Endoscopic examination and computed tomography scan showed no abnormal findings.Treatment with acetaminophen 800 mg daily was started,but the pain continued.

History of past illness

He had a past medical history of urolithiasis treated with medication.

Then suddenly the wood became full of a terrible noise; the trees began to groan24, the branches to creak and the dry leaves to rustle25, and the Baba Yaga came flying from the forest. She was riding in a great iron mortar26 and driving it with the pestle27, and as she came she swept away her trail behind her with a kitchen broom.

Personal and family history

ACNES is defined as chronic abdominal wall pain caused by entrapment of cutaneous branches of the lower thoracoabdominal intercostal nerves[4,5].The pain due to ACNES is refractory to treatment,can be sharp,dull or burning in character[4-6].Diagnosis of ACNES is based on clinical findings and excluding other diagnoses,which include bowel-related(functional abdominal pain;irritable bowel syndrome,constipation),gynecologic(ovarian cyst),pain after trauma or surgery,urologic(infection,),posture-related pain(orthopedic,)[4,7]and psychogenic abdominal pain[8].Therefore,routine postoperative pain should be excluded from consideration as ACNES[4].However,surgery was reported to cause ACNES in some patients[4].In the present patient,entrapment of an anterior cutaneous nerve by the operative scar was thought to be the most likely cause.The commonly held definition(above)of ACNES may be incomplete.The clinical entity of ACNES is a syndrome of the same type of pain.We would like to propose a new definition,in which ACNES is classified into primary and secondary types.Primary ACNES is defined as the originally characterized ACNES which is idiopathic in nature,and secondary ACNES is defined as anterior cutaneous nerve entrapment caused during the healing process after surgery or a traumatic injury.

Physical examination

The operating surgeon consulted with a pain specialist about the patient’s pain.The pain was characterized by sudden onset,continuing for a long time,and the pain intensity was reported as 5-6/10.The patient could indicate the location where the pain began,which was at the operative scar(Figure 1).Hypoesthesia was recognized using the cold test compared to the contralateral side(6/10).There was no numbness or allodynia at the location.Carnett’s test[4]was negative.

Laboratory examinations

Ultrasound examination.

Imaging examinations

The pain specialist imaged the operative scar with ultrasound and found an adhesion-like area on the posterior sheath of the rectus abdominis muscle(Figure 2A).

MULTlDlSClPLlNARY EXPERT CONSULTATlON

A rectus sheath block was performed with 20 mL of 0.1% lidocaine.The adhesion-like area was detached from the rectus abdominis muscle by hydrodissection(Figure 2B).

The authors declare that they have no competing interests.

She stretched her finger toward another object on the mantle. I allowed her to touch everything in sight, plants, glass objects, TV, VCR, lamps, speakers, candles and artificial flowers. If she started to grab, I gently reminded her to use one finger. She always obeyed. But, Hannah, an only child, possessed6 a more adventur ous personality. Her father predicted it would prevent her from accepting the one finger rule.

FlNAL DlAGNOSlS

ACNES was diagnosed in this patient.

TREATMENT

No expert consultation was conducted.

OUTCOME AND FOLLOW-UP

After hydrodissection,the pain was immediately relieved.The frequency of pain decreased to 0-1 episodes per month,and the duration of the pain decreased to several minutes for each episode.The patient was satisfied with the treatment and did not want any more nerve blocks.

Further diagnostic work-up

The pain specialist conducted a Carnett’s test again.Interestingly,these tests were positive this time,but the evoked pain was minimal.

DlSCUSSlON

No special notes.

Clinical findings of ACNES are characterized as a specific type of pain[4-8].The pain is always in the same location,just lateral to the middle of the abdomen,and provoked by daily activities[6].A special maneuver for diagnosis is Carnett’s test[4,7].A positive Carnett’s test means that tenderness is present when placing a finger on the pain location during abdominal muscle tensing caused by lifting the head or legs[4,7].In the present patient,the Carnett’s test was negative during the first physical examination,but was positive at the next physical examination.Physical findings strongly suggested that the pain was derived from the abdominal wall.Boelens[9],reported that a positive Carnett’s test in patients suspected to have ACNES was 88% sensitive,but inconclusive or negative tests were 9% and 3%respectively.In the present patient,Carnett’s test might not have been performed completely due to the patient’s fear of refractory pain.Some clinicians might not perform the physical test with sufficient strength at the first examination.This speculation might explain why the second test became positive.

Trigger point injection[10],transverse abdominis plane block[11]and rectus sheath block[12]and have been reported as useful examinations to establish the diagnosis and also the treatment of ACNES.In the present report,ACNES after a laparoscopic procedure was successfully treated with ultrasoundguided rectus sheath block.We speculate that if the anterior cutaneous nerve is entrapped as defined by ACNES,the main effect of rectus sheath block may be to release the entrapped nerve with hydrodissection rather than the effect of the local anesthetic.Recently,ultrasound-guided nerve hydrodissection has been established as a treatment for nerve entrapment[13].In experiments using animal models of neuropathic pain,nerve hydrodissection reduces nerve irritability and improves blood flow to the nerve by relieving pressure on the free nerve endings surrounding the epineurium and the feeding vessels[13].The application of ultrasound-guided techniques to the treatment of ACNES is still in development,and further studies will be needed to determine their efficacy.

CONCLUSlON

The number of laparoscopic procedures is steadily increasing,and chronic pain after laparoscopic surgery is also becoming more common[14].Some instances of pain were thought to be ACNES[15].To the best of our knowledge,this is the first report of ACNES induced by a laparoscopic procedure being treated successfully with ultrasound-guided rectus sheath block.Ultrasound-guided rectus sheath block is a potential solution to the etiology of ACNES itselfEffective treatment is needed for ACNES,and ultrasound-guided rectus sheath block may be an important part of the armamentarium.

FOOTNOTES

Sawada R and Tokumine J helped in writing the original draft;Watanabe K and Tokumine J helped in the conceptualization of the case report;Lefor AK helped in writing the review and editing the manuscript;Ando T and Yorozu T helped with literature acquisition and data validation.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial(CC BYNC 4.0)license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See:https://creativecommons.org/Licenses/by-nc/4.0/

It was a hug to make up for all those we had never had. Days later as he slowly started to gain strength he told me for the first time ever that he loved me, and through my tears I told him I loved him too.

He emptied the purse altogether and then shut it; when he opened it the fifty crowns were still there!Then a plan came into his head, and he determined to go at once to the Court tailor and coachbuilder

The authors have read the CARE Checklist(2016),and the manuscript was prepared and revised according to the CARE Checklist(2016).

Written informed consent was obtained from the patient for the publication.

I have given you all things, he said. Everything that is mine is yours! Give each other my love and you ll express my joy and feel my peace. Forever these things are yours. But I warn you. Never look to the nothingness for in that day you shall surely die!

Japan

Ryuji Sawada 0000-0002-1366-1364;Kunitaro Watanabe 0000-0002-8319-0406;Joho Tokumine 0000-0003-3481-2085;Alan Kawarai Lefor 0000-0001-6673-5630;Tadao Ando 0000-0002-9651-107X;Tomoko Yorozu 0000-0002-2161-4525.

Japanese Society of Anesthesiologists,00006209.

Liu JH

“Thank you very much,” I said, as we hugged each other. “Please give our love and thanks to the church.” Then I drove to a store near our home and purchased some much-needed items for the children.

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If anyone deserves a special day, it s these brave souls who ve had to carve out a place for themselves in readymade families with the care and caution of a neurosurgeon.

Liu JH