Rectus sheath catheterisation: a novel method of placement

Background

The benefits of good postoperative pain relief are well established and are fundamental to enhanced recovery programmes. ¹ This new method of inserting a rectus sheath catheter is quick and easy to perform at operation.

Technique

Before closing the rectus sheath, it is held up with tissue forceps on one side. The epidural needle is inserted longitudinally at a 20º angle to the peritoneum. The surgeon is able to feel a pop as the Tuohy epidural needle enters into the space between the peritoneum and the posterior rectus sheath (Fig 1). An epidural catheter is then fed through the needle into this plane, where its position can be confirmed by palpation (Fig 2). The needle is removed, leaving approximately 5cm of the catheter in place.

Figure 1. The epidural needle is inserted into the rectus sheath.

Figure 2. An epidural catheter is fed through the needle.

The epidural needle is reinserted through the anterior abdominal wall into the abdominal cavity (Fig 3). The catheter is fed through the needle retrogradely (Fig 4) and brought out to the surface. The needle is removed by sliding it over the catheter, ensuring the end of the catheter remains in its position in the rectus sheath. A bacterial filter is attached to the catheter, flushed and fixed with dressings. Subsequently, 15ml of 0.25% bupivacaine local anaesthetic is injected through the catheter and given every 6 hours for 72 hours before removal of the catheter.

Figure 3. The epidural needle is reinserted into the abdominal cavity.

Figure 4. The catheter is fed into the needle retrogradely.

Discussion

The use of rectus sheath blocks as an alternative method of analgesia is well described ^2,3 but has previously relied on ultrasonography guidance. This method of insertion is simple to learn and replicate, and has gained good patient feedback.