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• W2100021782 abstract "Editor'We read with considerable interest the letter by Mokini and colleagues1Mokini Z Buccino G Vitale G Mauri T Fumagalli R Pesnti A Psoas compartment block for anaesthesia during surgical repair of inguinal hernias.Br J Anaesth. 2013; 111: 298-299Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar about the psoas compartment block (PCB) as a sole anaesthetic technique for surgical repair of inguinal hernias. Although we encourage the use of this technique for less obvious surgeries and therefore congratulate the authors on this publication, we still have some remarks and concerns related to the use of this technique for lower abdominal wall surgery. The L2–3 approach of a PCB presented by the authors was first described by Hanna and colleagues2Hanna MH Peat SJ D'Costa F Lumbar plexus block: an anatomical study.Anaesthesia. 1993; 48: 675-678Crossref PubMed Scopus (47) Google Scholar in 1993; therefore, the technique described by Mokini and colleagues actually is a well-known approach of the PCB rather than a modification of a PCB as suggested by the authors. However, as rightly recognized by the authors, the use of this technique has some restriction which should be known to physicians before considering this technique for inguinal surgery. In contrast with lower lumbar dermatomes, the higher lumbar dermatomes are unreliably blocked by a PCB, regardless of which approach has been used.3Mannion S Psoas compartment block.Contin Educ Anaesth Crit Care Pain. 2007; 5: 162-166Abstract Full Text Full Text PDF Scopus (20) Google Scholar A possible explanation for this is the anatomic location of the lumbosacral plexus. Kirchmair and colleagues4Kirchmair L Lirk P Colvin J Mitterschiffthaler G Moriggl B Lumbar plexus and psoas major muscle: not always as expected.Reg Anesth Pain Med. 2008; 33: 109-114PubMed Google Scholar reported that in the majority of cases, the lumbosacral plexus lies within the psoas major muscle, and not inside a sheath between the muscles. We wonder if the reproducibility of this technique was also tested in a hernia repair patients group. Furthermore, the authors rightly pointed out some serious complications of a PCB such as hypotension, epidural- or subarachnoid spread, systemic toxicity, renal puncture, and retroperitoneal haematoma. A more cephalad approach of the PCB like the L2–3 approach suggested by the authors could be more prone to an unattended puncture of the kidney. The most frequently occurring undesirable side-effect of a PCB is a bilateral spread of the injected local anaesthetics, resulting in epidural anaesthesia.5Touray ST de Leeuw MA Zuurmond WW Perez RSGM Psoas compartment block for lower extremity surgery: a meta-analysis.Br J Anaesth. 2008; 101: 750-760Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar It was previously thought that the occurrence of bilateral spread depended on the approach taken for a PCB. However, Gadsden and colleagues6Gadsden JC Lindenmuth DM Hadzic A Xu D Somasundarum L Flisinsky KA Lumbar plexus block using high-pressure injection leads to contralateral and epidural spread.Anesthesiology. 2008; 109: 683-688Crossref PubMed Scopus (70) Google Scholar concluded that injection of a local anaesthetic with high injection pressure (>20 psi) during lumbar plexus block commonly results in unwanted bilateral block and is associated with high risk of neuraxial block. Mokini and colleagues did not describe any injection pressure or assessment of bilateral local anaesthetic spread resulting in an epidural anaesthesia in their patient(s). In theory, the suitability of the PCB as anaesthetic technique for inguinal hernia repair suggested by the authors could be erroneously attributed to unnoticed epidural anaesthesia. Finally, in a time of increased emphasis on patient safety, information with regard to success rate or complication rate of this technique for inguinal surgery is needed. In that sense, some data with regard to the number of patients anaesthetized with this technique and the reliability of the result thereof would have been helpful. Until then, in our opinion, the lack of reliability regarding blocking dermatome L1, together with the fact that this technique probably does not anaesthetize manipulations of the spermatic cord and the peritoneum sac (also described by Mokini and colleagues), makes this technique unsuitable for most patients undergoing inguinal hernia surgery. None declared." @default.
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• W2100021782 title "Psoas compartment block for surgical repair of inguinal hernias" @default.
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