Dear Editor,
We thank the authors of the article “Revisiting the Deep Rectus Sheath Block: An Anatomical Mismatch for Visceral Analgesia”[1] for their careful comments on our article, “Deep Rectus Sheath Block: A Novel Pain Management Approach after Laparoscopic Cholecystectomy.”[2]
Our technique involves ultrasound-guided deposition of local anaesthetic (LA) deep to the posterior rectus sheath, aiming to access the preperitoneal compartment. While similar approaches exist, our goal was to present a reproducible, clinically supported technique. An ultrasound-guided technique has been described that focuses on targeting the appropriate plane properly.[3] Although the transversalis fascia—a thin connective layer between the posterior sheath and preperitoneal fat[4]—is often not clearly visualised on ultrasound, we consistently observed LA spread in the intended preperitoneal space.
Clinically, the DRS block appears beneficial as part of a multimodal analgesia regimen for laparoscopic cholecystectomies, hernia repairs,[5] and laparotomies[6] procedures that involve both somatic and visceral nociception. The rich vascularisation raises the plausibility that systemic LA absorption may be responsible for analgesia, a known mechanism in all fascial plane blocks. We agree that the ilio-hypogastric and ilioinguinal nerves are probably not involved, and acknowledge that any autonomic spread remains hypothetical. LA spread to the thoracic paravertebral area causes relief of both visceral and somatic pain during abdominal procedures. Fascial continuity, by itself, does not guarantee such a distribution. We support the authors’ call for further imaging and cadaveric studies and are currently exploring such investigations.
We appreciate the authors’ engagement, which contributes to refining and clarifying the understanding of this evolving technique.
Conflicts of interest
There are no conflicts of interest.
Presentation at conferences/CMEs and abstract publication
Nil.
Study data availability
De-identified data may be requested with reasonable justification from the authors (email to the corresponding author) and shall be shared after approval as per the authors’ institution’s policy.
Disclosure of use of artificial intelligence (AI)-assistive or generative tools
The AI tools or language models (LLM) have not been utilised in the manuscript, except that software has been used for grammar corrections and references.
Declaration of use of permitted tools
Not applicable.
Authors contributions
FM was involved in concepts, design, data curation, methodology, conduct of cases, data acquisition, manuscript preparation, editing and review. MT was involved in concepts, design, data curation, conduct of cases, data acquisition, literature research, manuscript editing and review. CP was involved in concepts, design, manuscript editing and review. PFF was involved in concepts, design, data curation, methodology, manuscript preparation, editing and review, and supervision.
Supplementary material
This article has no supplementary material.
Acknowledgements
Nil.
Funding Statement
Nil.
REFERENCES
- 1.Sonawane K, Naveena NR, Mistry T. Revisiting the deep rectus sheath block: An anatomical mismatch for optimal analgesia. Indian J Anaesth. 2025;69:1078–81. [Google Scholar]
- 2.Marrone F, Tomei M, Pullano C, Fusco P. Deep rectus sheath block: A novel pain management approach after laparoscopic cholecystectomy – A case study. Indian J Anaesth. 2025;69:515–6. doi: 10.4103/ija.ija_1366_24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Fusco P, Stecco C, Nazzarro E, Sanapo A, DE Sanctis F, Scarcella M, et al. Under the fascia: Technique for performing the deep rectus sheath block. 2025 Minerva Anestesiol. 2025;91:595–6. doi: 10.23736/S0375-9393.25.18830-5. [DOI] [PubMed] [Google Scholar]
- 4.Standring S. Grey’s Anatomy. 42nd. London: Elsevier Limited; 2021. Anterior abdominal wall; pp. 1128–30. [Google Scholar]
- 5.Marrone F, Sorrentino T, Paventi S, Tomei M, Sbucafratta L, Fusco P. Deep rectus sheath block: A novel approach to pain management after epigastric hernia repair-A case series. A A Pract. 2025;19:e01987. doi: 10.1213/XAA.0000000000001987. doi: 10.1213/XAA.0000000000001987. [DOI] [PubMed] [Google Scholar]
- 6.Petroni GM, Sanapo A, DE Sanctis F, Nazzarro E, Ciaschi W, Maggiani C, et al. The deep rectus sheath block plus rectus sheath block in awake laparotomy surgery in the elderly patient. Minerva Anestesiol. 2025;91:473–4. doi: 10.23736/S0375-9393.24.18731-7. [DOI] [PubMed] [Google Scholar]