Anaesthesia, 1991, Volume 46, pages 875-877

Forum Rectus sheath and mesosalpinx block for laparoscopic sterilization

B.E. Smith FFARCS, Consultant Anaesthetist, G.H. MacPherson, FRCOG, Consultant Gynaecologist, M. d e Jonge DA (UK), Registrar, J.M. Griffiths MB, ChB, Senior House Officer, Departments of Anaesthetics a n d Gynaecology, Alexandra Hospital, Woodrow Drive, Redditch, Worcs B98 7UB.

Summary Thirty patients scheduled to undergo laparoscopic sterilisation were allocated at random to receive either a standardised general anaesthetic and rectus sheath block (group A ) , or standardised general anaesthetic combined with both rectus sheath and mesosalpinx blocks (group B ) . Group B patients had significantly less postoperative pain, as assessed by linear analogue scores ( p < 0.025), and analgesic requirement ( p < 0.05). By the 8th postoperative hour all 15 group B patients had been discharged from hospital, whilst only seven of I5 patients in group A were considered suitable f o r discharge at this time. ( p < 0.05). Key words Anaesthetic techniques, regional; rectus sheath block, mesosalpinx block. Surgery; laparoscopy. Fain; postoperative.

Following the demonstration that the use of bilateral rectus sheath block can reduce significantly postoperative pain after diagnostic laparoscopy,' the same technique was applied in patients undergoing laparoscopic sterilisation. During the course of a pilot study it became clear while abdominal wall pain was obtunded, most patients complained of deep pelvic pain, similar to dysmenorrhoea. As these symptoms had not been reported during the diagnostic laparoscopy study, but had been observed by gynaecologists following sterilisation with Falop rings in other patients, we concluded that they were probably attributable to the occlusion of the Fallopian tube. The Fallopian tube has no demonstrable somatic nerve supply, but has autonomic innervation via the mesosalpinx. Local anaesthetic blockade of the mesosalpinx adjacent to the point of Fallopian occlusion should interrupt autonomic afferents and prevent perception of pain. This study was undertaken to test this hypothesis in the clinical situation. Patients and methods

The study was approved by the district ethics committee and 30 patients of ASA grades 1 or 2 scheduled to undergo laparoscopic sterilisation were investigated. Formal consent was obtained from the patients following both verbal and written description of the proposed research. All patients were admitted as unpremedicated day cases and were allocated to either group A or group B on the basis of a random number sequence. Group A patients received a standardised general anaesthetic sequence comprising alfentanil 30 pg/kg, propofol 2.5-3.0 mg/kg and vecuronium 0.1 mg/kg. The trachea was intubated and anaesthesia maintained with 66% nitrous oxide in oxygen, with 0.5% halothane if clinically indicated. Bilateral rectus sheath block was performed

using a mixture of equal parts of prilocaine 1% and bupivacaine 0.5% without adrenaline, in a volume of 0.25 ml/kg per side.' Neuromuscular block was antagonised at the end of the procedure with neostigmine 50 pg/kg and glycopyrronium 20pg/kg. In group B, an identical sequence of general anaesthesia and rectus sheath block was employed. In these patients mesosalpinx block was performed under direct vision by the surgeon at laparoscopy . Technique of mesosalpinx block. A standard two-puncture laparoscopic technique was used with carbon dioxide as the insufflating gas. Each Fallopian tube was identified and ligated with a Falop ring 2-3cm from the uterine cornu. With the tube still held in the ring applicator forceps, a 20 gauge x 5 inch (12.5 cm) spinal needle was inserted 3 cm above and 5 cm lateral to the pubic symphysis on the appropriate side. The needle was advanced under direct vision, through the posterior leaf of the mesosalpinx about 1 cm below the position of the Falop ring and 2-3 ml of bupivacaine 0.5% without adrenaline injected. At the end of the procedure the pneumoperitoneum was reduced as far as possible before withdrawing the laparoscope sheath. Analgesic prescribing All patients were prescribed intramuscular papaveretum 0.25 mg/kg 3-hourly as required and oral dihydrocodeine 60 mg 4-hourly as required. The decision to administer analgesia and the choice of analgesic were left in the hands of the nursing staff, who were blind to the patient grouping. Postoperative assessment All patients were assessed by an independent observer at 1 and 4 hours postoperatively, and again at 8 hours after operation if they had not been discharged. The decision to discharge the patient was left to the anaesthetic and gynaecology junior staff, who were blind to the patient grouping. (The protocol allowed for

Accepted 1 December 1990 0003-2409/91/100875 + 10 $03.00

@ 1991 The Association of Anaesthetists of Gt Britain and Ireland




Table 1. Visual analogue scores at each postoperative assessment, where 0 represents no pain and 10 severe pain. Figures are means

(range). Group A (control)

Group B (study)

n = 15

1 hour

4 hour

5.24 (1.8-8.3) 2.71 (1.6-5.2)

Table 3. One hour postoperative assessment. Number of patients in each group who complained of postoperative pain according to site.


Group A


1 11




2 3

3 2

Rectus sheath and mesosalpinx block for laparoscopic sterilization.

Thirty patients scheduled to undergo laparoscopic sterilisation were allocated at random to receive either a standardised general anaesthetic and rect...
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