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Surgical Techniques in Urology

Access to the Extrapleural Space at the Time of Surgery for Continuous Paravertebral Block After Flank Incision: Description of the Technique and Case Series

Gavin M. Langille, Gordon O. Launcelott, and Ricardo A. Rendon

OBJECTIVE To test our hypothesis that surgeon-placed paravertebral block (PVB) placement during open renal surgery is effective, feasible, and safe. Neuraxial analgesia represents the current standard of care for perioperative anesthesia for open renal surgery. However, potential catastrophic complications such as neuraxial bleeding and infection may occur. An alternative to neuraxial analgesia widely used in thoracic surgery is the surgeon-placed PVB.

TECHNICAL

CONSIDERATIONS the time of surgery. The postoperative catheter management was directed by anesthesiologists. All patients undergoing open renal surgery by a single urologist were provided a PVB for this series. Twenty-nine consecutive patients undergoing open renal surgery were given PVBs. Patients received an average of 5.1 mg of subcutaneous equivalent hydromorphone in the 48-hour postoperative period. No complications because of the PVB were found. CONCLUSION PVB represents a safe and effective surgeon-placed alternative to neuraxial analgesia for open

The surgeon-placed catheter is directed in the paravertebral space through the ank incision at

renal operative procedures.

UROLOGY 81: 675e 678, 2013. 2013 Elsevier Inc.

N euraxial analgesia represents the gold standard

in pain control for major abdominal and ank

incisions used for open urologic procedures. It

can decrease the stress response and improve postoperative respiratory function by reducing perioperative opioid requirements. 1 This works to minimize the systemic side effects of opioids such as nausea, pruritus, urinary retention, and ileus. Although rare, potential complications include epidural hematoma or abscess, which can lead to perma- nent neurological de cits. Epidural abscess has been documented at widely variable rates, some of the higher incidences reported at 1:800 to 1:1930. 2,3 In a large series, the rate of epidural hematoma was 1:4105. 4 Neuraxial analgesia is contraindicated in patients requiring certain perioperative anticoagulation or antiplatelet regimens, which has furthered interest in alternative techniques. Anesthesiologist-administered paravertebral block (PVB) has been described in the literature as a technique for post- operative analgesia for renal surgery. 5 This technique does not carry the potential risks of neuraxial bleeding, but maintains benets such as decreased opioid use. Additional

Financial Disclosure: The authors declare that they have no relevant nancial interests. From the Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada; and Department of Anesthesia, Dalhousie University, Halifax, Nova Scotia, Canada Reprint requests: Ricardo A. Rendon, M.D., F.R.C.S.C., Department of Urology, Dalhousie University, 5015 5th Floor, Victoria General Hospital, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9, Canada. E-mail: rrendon@dal.ca Submitted: July 5, 2012, accepted (with revisions): November 27, 2012

ª 2013 Elsevier Inc. All Rights Reserved

benets over neuraxial analgesia include preservation of forced vital capacity, minimizing respiratory depression, and limiting hypotension. 6 For thoracotomy incisions, PVB has been proposed to represent the new gold standard over neuraxial analgesia. 7 Placement of the paravertebral block into the extrapleural space has traditionally been performed by an anesthesiologist using a percutaneous ultrasound- guided technique. This approach requires operator experi- ence and skill; it has had varied degrees of success and is less reliable and prone to more side effects than catheters placed under direct vision. 8 The use of surgeon-placed PVBs in the thoracic literature is gaining in popularity. 9,10 Surgeon-placed PVB during posterolateral thoracotomy has been shown to decrease postoperative opioid requirements compared to epidural. 11 It also avoids possible neuraxial placement, which is pos- sible with an anesthesiologist-applied block. 9 We hypoth- esize that a surgeon-placed PVB under direct vision via a ank approach during renal surgery is a feasible procedure that can provide effective perioperative analgesia without the risks associated with neuraxial analgesia.

MATERIALS AND METHODS

Neuroanatomy

A discussion on the relevant anatomy is warranted. As the thoracic spinal nerve root leaves the intervertebral foramen, it immediately gives off a small posterior branch (posterior primary ramus). The main nerve crosses the paravertebral space and into

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the intercostal space in the plane between the pleura anteriorly and the posterior intercostal membrane. Beyond the angle of the rib, the nerve lies inferior to the intercostal vessels sandwiched between the intercostalis intimus anteriorly and the internal intercostal muscle, continuing in this plane until it reaches the anterior axillary line. At this point, the intercostalis intimus terminates and the nerve once again comes to lie directly on the pleura. In the ank, as the 10th thoracic nerve passes beyond the costal cartilage, it will come to lie on the pleura, the dia- phragm, and the transversus abdominis muscle as it makes its way toward the anterior abdominal wall ( Fig. 1 ). It is here that the extrapleural space can be accessed at the time of surgery and a catheter placed in the paravertebral gutter under direct vision for local anesthetic in ltration. It is this anatomic relationship of the thoracic spinal nerve roots and intercostal nerves sandwiched between the pleura and the chest wall within the thoracic cavity that provides an opportunity for local anesthetic to spread and block several spinal nerve roots. Furthermore, if this space can be accessed easily at the time of surgery, a catheter can be placed under direct vision allowing for continuous infusion of local anesthetic and prolonged unilateral peripheral nerve block.

Technique

Toward the end of the surgical case, after the completion of the urologic intervention, attention is turned to PVB placement. The anterolateral aspect of the diaphragm is identi ed where it crosses the 10th and 11th ribs ( Fig. 2). The parietal pleura is subsequently identi ed beneath the diaphragm. The parietal pleura are dissected bluntly from the 10th rib. This plane is widened with blunt dissection. The extrapleural plane is devel- oped superoposteriorly to the necks of the 8th through 12th ribs. Exposure is aided with the use of a narrow Ribbon retractor and adequate illumination. Under direct vision, a Tuohy (17 gauge, 3.5 inches; Becton, Dickinson and Co., Franklin Lakes, NJ) epidural needle is passed percutaneously over the 11th rib approximately 10 cm lateral to the spine. Care is taken to protect the pleura and the lung. An epidural catheter is passed through the Tuohy needle under direct vision and is directed into the paravertebral space ( Fig. 3). The Tuohy needle is removed and

the epidural catheter is xed externally to the skin with adhesive tape, as per the technique used in neuraxial analgesia. The pleura and lung are allowed to fall back into place. What remains is

a standard extended posterolateral retroperitoneal incision

closure in layers. The diaphragm is reapproximated to the deeper

fascial layer with a continuous suture. Twenty-nine consecutive patients who had PVB during open partial or radical nephrectomy by a single surgeon were reviewed. Research ethics board approval for this study was obtained. All incisions were made superior to the 11th rib.

A 20 mL bolus of 0.5% bupivacaine was administered to all

patients via the extrapleural catheter intraoperatively. A maintenance infusion of 0.375% ropivicaine at 12 mL per hour was provided. Anesthesiologists maintained control over the management of the paravertebral catheters. All patients received acetaminophen 975 mg orally every 6 hours, as per our care map to supplement the PVB postoperatively. Additional opioid administration was at the discretion of the anesthesiol- ogist directed Acute Pain Service while the PVB was in place. Opioid requirements were converted to parenteral equivalent hydromorphone based on accepted ratios. 12,13 The parenteral to oral equivalent ratio of morphine and hydromorphone is 1:3 and 1:5, respectively. The conversion ratio of oral morphine to oral

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The conversion ratio of oral morphine to oral 676 Figure 1. A window has been cut

Figure 1. A window has been cut through the external and internal oblique muscles showing the 9th and 10th thoracic nerves, lying successively on the pleura, diaphragm, and transverses abdominis. This gure was reproduced with permission: initially published as Figure 43 in Local Anal- gesia Abdominal Surgery MacIntosh and Bryce-Smith, Copyright: Elsevier, E & S Livingstone Ltd, Edinburgh and London (1962).

hydromorphone is 1.5:10. Paravertebral catheters were removed once the anesthesiology team felt the analgesia to be adequate, and all were removed by 72 hours postoperatively.

RESULTS

Twenty-nine consecutive patients who had open partial or radical nephrectomy by a single surgeon were reviewed. The cases were dated from November 2008 to July 2011. All patients had PVB placement performed intra- operatively. All incisions were made superior to the 11th rib. Twenty- ve partial and 4 radical nephrectomies were included in this study. In all cases, the surgical dissection of the extrapleural plane and intraoperative paravertebral catheter placement were successful. The average amount of intravenous hydromorphone used in the postanesthetic care unit was 1.24 mg. Over half of these patients received 1 mg or less of hydromorphone, with 6 of these patients receiving none. Parenteral equivalent hydro- morphone used in the initial 48 hours on the surgical oor was 3.87 mg. For the 6 hours before PVB removal,

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Figure 2. Dissection of the diaphragm to develop the plane leading to the extrapleural space

Figure 2. Dissection of the diaphragm to develop the plane leading to the extrapleural space during ank surgery. The highlighted anatomic relations demonstrating a patient lying in the left lateral decubitus position are maintained for Figure 3. The bolstering suture can be visualized on the cranial aspect of the right kidney. Rt, right.

on the cranial aspect of the right kidney. Rt, right. Figure 3. The epidural catheter is

Figure 3. The epidural catheter is passed through the Tuohy needle below the 10th rib and fed into the paravertebral space. Rt, right.

systemic narcotic administration was 38% less than the 6 hours after PVB removal. The average length of stay in the hospital was 4.4 days. No complications were found to be associated with the use of this technique.

COMMENT

We present this technique as a feasible and safe surgeon- applied procedure that provides excellent postoperative analgesia to patients undergoing lateral lower thoracotomy. PVB provides similar bene ts of neuraxial analgesia including minimal systemic opioid use with excellent pain control while avoiding complications from neuraxial analgesia such as epidural abscess and hematoma. An- other advantage is the ability to place a PVB under direct vision, a surgeon-directed maneuver performed during

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the operation. This facilitates the short learning curve associated with this procedure. PVB placement is safe in our experience, with no per- ioperative complications related to its placement or use. Potential complications of PVB include bleeding most commonly in the form of a limited hematoma, which is reported at 2.4% for anesthesiologist-placed blocks. 6 Pneumothorax and pleural puncture rates were reported as 0.5% and 1%, respectively, for anesthesiologist-placed PVB. Anesthetic toxicity is also a possibility. 14 Although infection is possible, the risk of infection in the epidural space is avoided by using the surgeon-placed approach. Placement of the paravertebral catheter in the extrap- leural space is a relatively straightforward procedure that we feel has a much shorter learning curve than the ultrasound-guided anesthesiologist-directed technique. The ease of use is facilitated by the ability to place the catheter under direct vision during the procedure. In the current series, paravertebral catheters were successfully placed in the paravertebral space. The development of the extrapleural space and catheter insertion adds only several minutes to the overall procedure. Patients in this series had a variety of requirements for systemic postoperative opioids, many with near negligible amounts considering the usual pain derived from a ank incision. A variety of factors including body habitus and length of incision could in uence opioid requirements. Twenty-six of the 29 patients received just 2.0 mg or less of intravenous hydromorphone in the postoperative recovery room. Analgesic requirements on the surgical oor showed that almost half (48%) of the patients in this series had 4 mg or less of equivalent parenteral hydro- morphone in the 48-hour postoperative period. For this same period, 2 patients required 10 mg or more of equivalent parenteral hydromorphone. The total anal- gesic requirements for these 2 patients was still slightly less than the previously reported amount for open nephrectomy without neuraxial analgesia, with our median requirement just half of this value. 15 Compared to previous data on neuraxial and PVB for posterolateral thoracotomy, the 48-hour total opioid requirements in our patients was 29% and 12% less, respectively. 11 Compared to another series of surgeon-placed PVB for thoracotomy, our opioid requirements were nearly iden- tical. 16 Total narcotic requirements were similar compared to open nephrectomy in another series. 17 The possibility exists that suboptimal placement or displace- ment of the catheter could lead to decreased efcacy, although we feel that the straightforward placement of the PVB minimizes this risk. Further investigations into factors that in uence the effectiveness of PVB include correlating individual characteristics such as age, weight, and body mass index, etc., in a larger data set. The limitations of this study include its retrospective, nonblinded nature with no control group. Although this review serves as a proof of principle for the use of surgeon-placed PVB in the urologic literature, further prospective and randomized trials would help solidify

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the use of PVB by urologists for renal surgery. At our institution, the PVB is now used for all open renal and adrenal surgeries. Because of the excellent results observed, this technique has been expanded to other procedures using lower lateral thoracotomies (such as abdominal aortic aneurysm repair).

CONCLUSION

The use of surgeon-placed PVB intraoperatively is feasible and provides safe and effective perioperative analgesia for open renal and adrenal surgery using the ank approach based on these initial results. PVB placement has become the mainstay for anesthetic delivery for all open renal and adrenal surgery at our institution.

Acknowledgments. The authors thank Sebastian Launcelott and Lynn Langille for their contributions to this project.

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Video Clips cited in this article can be found on the internet at: http://www.goldjournal.net

Video Clips cited in this article can be found on the internet at: http://www.goldjournal.net

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