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Preoperative Evaluation/Patient Issues/Abdominoplasty and postoperative pain

QUESTION:

We are just starting to do "tummy tucks" at our ambulatory surgery center. Are there any special techniques for post-op pain control that other centers are having success using?

-- From T. Wilhite, M.D., Missouri

REPLY:

With regards to "tummy tucks," or abdominoplasty, a very successful technique to both reduce GA requirements procedure, and to provide postoperative pain control, is the paravertebral block (PVB).

In the preoperative holding area or induction room, the patient is placed sitting with monitors and oxygen in place, and is sedated with midazolam and fentanyl. The midpoint of the spinous process of T2-T10 is marked, and a point 2.5 cm lateral to this is marked on each side of the spinous process. Local anesthestic is infiltrated along a line connecting these points unilaterally on each side of the spinous process. Then, using a 22 gauge Tuohy needle, 3-4 mL of 0.5 % Ropivicaine is injected 1 cm deep to the transverse process at these points bilaterally at each level. Since, yes, up to 18 individual injections are involved, the subcutaneous local anesthetic placed before the procedure is a very important factor in ensuring patient comfort.

With 3 mL volumes per injection, epidural spread is rare but possible. Similarly, the local anesthetic concentration can be reduced slightly for less heavy patients (for example, to 0.375% ropivacaine), but a shorter analgesic duration should be anticipated. Additives (e.g., clonidine, buprenorphine) have not been sufficiently studied specifically for PVBs to warrant recommendations regarding routine additive use in this block.

The needle should not be inserted more than 4 cm without contacting transverse process and then should be walked off inferior to decrease chance of pneumothorax. The operator will commonly feel a "pop" or "crunching" as the needle passes through the costotranverse ligament. After negative aspiration to heme, CSF, and/or air, the solution is injected.

Within 10-15 minutes these patients notice a difference to scratching with the corner an alcohol swab, and can usually undergo the procedure with roughly "half a MAC" of anesthetic agent, (or preferably propofol in a much lower dose as part of a total intravenous technique, to minimize postoperative nausea and/or vomiting), as well as no requirement for narcotics or nitrous oxide. Patients usually wake up extremely comfortable, and are discharged home significantly sooner than when GA is used alone, in my experience.

-- From Don Siwek, M.D., Bloomfield Hills, Michigan

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Don Siwek describes using paravertebral blocks from T2 to T10 to provide intraoperative and postoperative analgesia in abdominoplasty.

In the cases I have seen, the more caudad incision is made in roughly the T11 dermatome, and dissection/undermining is carried out caudad to that incision.

Why does Dr. Siwek stop at T10? I am also surprised that going as high as T2 is useful here.

--From - Jim Saklad, MD

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Clarification, for breast surgery, I block T2-T 6-7, for abdominoplasty T5-6 to T10-11. I have found the undermining that takes place, sometimes up to the xiphoid is the most uncomfortable postop. They usually remove an eliptical pannus just below the umbilicus as you noted but I think since that tissue is removed, only the inferior incision edge and the inferior undermining (1-2 dermatomes ) is sore. Also, I avoid going too low because these levels are estimates at times and if L1 is inadvertantly blocked directly or by spread some quadricep weakness could occur.

Thanks for your reply,

-- From - Don Siwek, MD

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