Sir:
Isolation of the iliohypogastric nerve for lytic blockade can be difficult because of its location within the fascial plane, between the internal oblique and the transversus abdominis muscle layers.1 2–4
Ilioinguinal/iliohypogastric block is used to provide intraoperative and postoperative analgesia for hernia repair.3,4 It may also be used for diagnostic nerve block or a therapeutic series of injections for patients suffering from chronic pain after hernia repair.
A 58-year-old woman was referred to the pain service with complaints of burning right lower abdominal pain for 2 continuous years. Iliohypogastric nerve blocks were performed using ultrasound guidance. This was repeated three times after the initial block provided 100 percent pain relief lasting approximately 4 weeks. A fluoroscope-guided iliohypogastric nerve cryoablation provided complete pain resolution lasting 4 weeks followed by complete return of symptoms. She decided to proceed with surgical excision of the right iliohypogastric nerve.
The right anterior superior iliac spine was palpated, and scanned and imaged by means of ultrasound using a linear array probe set at a depth of 3 cm (Fig. 1 ). The probe was moved medially 6.35 cm in the horizontal axis, where the iliohypogastric nerve was identified within the fascial plane between the internal oblique and the transversus abdominis muscles. The iliohypogastric nerve was centered in the ultrasound image field and held in place. A 14-gauge Angiocath (Becton, Dickinson and Company, Franklin Lakes, N.J.) was placed with its tip within 0.25 cm of the iliohypogastric nerve approached from the lateral edge of the ultrasound probe, and an 18-gauge, 3.5-inch Wingless Tuohy-Schiff needle (B-Braun Medical, Bethlehem, Pa.) was placed with its tip within 0.25 cm of the iliohypogastric nerve approached from the medial edge of the ultrasound probe. Both the 14-gauge Angiocath and the Tuohy needle were positioned by means of ultrasound guidance. The Tuohy needle was connected to a continuous infusion line consisting of 500 cc of normal saline; a 2.7-meter Continu-Flo Solution Set, Interlink System (Baxter Healthcare Corp., Deerfield, Ill.); a large-bore, four-way stopcock; and an Interlink System 103-cm extension set. A 20-cc syringe was connected to the three-way stopcock. Flow was regulated by a roller clamp on the extension set, and boluses to expand the perineural space were administered by means of the 20-cc syringe. An 18-gauge cryoprobe was inserted through the 14-gauge catheter and positioned in direct contact with the iliohypogastric nerve. The perineural space was expanded with a 3-cc bolus of normal saline administered by means of the 20-cc syringe under ultrasound guidance. Cryoablation was begun and completed in two 3-minute cycles. For surgical excision, this technique was repeated however a catheter was placed beside the nerve to elucidate surgical exploration and nerve identification.
Fig. 1: Ultrasound-guided 14-gauge angiocatheter insertion (orange arrow ) for hydrodissection (orange star ) of the iliohypogastric nerve (red arrow ) with catheter insertion (yellow arrow ).
Ultrasound-guided blockade of both the ilioinguinal and the iliohypogastric nerves has been described as an alternative to the blind standard technique as demonstrated in cadaveric models.5
DISCLOSURE
The authors have no financial interest in any of the products or devices mentioned in this communication. No external funding was received.
Adam C. Adler, M.D., M.S.
Department of Anesthesiology
Baystate Medical Center
Springfield, Mass.
Daryl I. Smith, M.D.
Department of Anesthesiology
University of Rochester School of Medicine and Dentistry
Rochester, N.Y.
Pranay M. Parikh, M.D.
Department of Surgery
Division of Plastic Surgery
Baystate Medical Center
Springfield, Mass.
REFERENCES
1. Eicehenberger UBigeleisen P, Orebaugh S, Monayeri N. Ultrasound-guided inguinal nerve block. Ultrasound-Guided Regional Anesthesia and Pain Medicine. 2010 Philadelphia Lippincott Williams & Williams:89–93
2. Campos NA, Chiles JH, Plunkett AR. Ultrasound-guided cryoablation of genitofemoral nerve for chronic inguinal pain. Pain Physician. 2009;12:997–1000
3. Trescot AM. Cryoanalgesia in interventional pain management. Pain Physician. 2003;6:345–360
4. Narouze SN, Zakhary E, Basali A. Genitofemoral and ilioinguinal neuralgia after laparoscopic versus open inguinal herniorrhaphy. Paper presented at: American Society of Regional Anesthesia & Pain Medicine Annual Fall Pain Meeting & Workshops; November 7–10, 2002; Phoenix, Ariz
5. Eichenberger U, Greher M, Kirchmair L, Curatolo M, Moriggl B. Ultrasound-guided blocks of the ilioinguinal and iliohypogastric nerve: Accuracy of a selective new technique confirmed by anatomical dissection. Br J Anaesth. 2006;97:238–243
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