WEBVTT - Dr Ramshaw CC Video Transcript

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I am Bruce Ramshaw. 

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I'm the Professor and Chair of 
Surgery at the University of 

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Tennessee in Knoxville. 

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I work with the University of 
Tennessee Medical Center and 

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Graduate School of Medicine. 

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Today we had a patient with an 
abdominal wall reconstruction redo. 

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She'd had multiple previous 
operations, the most recent was an 

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open component separation with an 
onlay with a biologic mesh. 

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Unfortunately, she developed chronic
pain and distention and a diastasis. 

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The biologic mesh had stretched, 
and she had some eventration and 

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we did another abdominal wall 
reconstruction using a synthetic 

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mesh that's made out of randomly 
oriented microfibers of polypropylene. 

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Hopefully more biocompatible and 
placed in a retro rectus position 

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using a transversus abdominis release. 

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And so, we were able to get a 
reconstruction with a lot more 

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integrity less likely to stretch and 
break down than what she had had 

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in the past. 

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I think like most surgeons, and our 
hernia team we were relying heavily 

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on the opioid pain medications. We 
saw the benefit, being the patient 

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didn't experience pain, but some of 
the negatives were, they weren't 

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able to take a deep breath, get up 
and move around. 

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They often were in and out of 
doziness and sleeping and often 

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they got nausea. 

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Part of the reason they couldn't get 
out of bed was because they were 

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nauseated and really couldn't move, 
had to keep the room dark, You know 

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had to keep aa pillow over their head. 

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And so, the opioids, although it made 
us feel better, the patient, I think 

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wasn't getting the optimal 
perioperative recovery and the 

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concepts of enhanced recovery and 
the ability to get up and move and 

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eat and do things that we want to 
see patients able to do quicker. 

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That wasn't being achieved with an 
opioid primary strategy. 

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The long-acting local anesthetic we 
have started to use is as part of our 

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continuous quality improvement 
effort with our hernia program. 

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A few years ago, we saw the 
opportunity to try to decrease the 

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experience of pain. 

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I think what we're seeing in our 
program and across healthcare 

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is more of an attention to the patient 
perspective, the ability to see what 

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it's like to go through surgery and 
recovery and learn that you know 

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there are a lot of things we can do 
better when you look it up from the 

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patients' perspective and pain is one 
of the major things that patients are 

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afraid of. 

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They come in with a lot of anxiety, 
apprehension, especially if they've 

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had prior surgery and they've had a 
negative experience. 

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So, to be able to have a better 
strategy for pain control and to help 

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patients understand the opportunity 
to lessen the impact of opioids in 

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their preoperative care and recovery. 

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It's been part of our continuous 
quality improvement in terms of 

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trying to improve value to the patient.

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Today I'm performing an abdominal 
wall reconstruction with a 

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transversus abdominis release approach. 

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When determining the most 
appropriate expansion volume to use 

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for any procedure with EXPAREL, 
it's important to consider the size of 

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the surgical site where the product 
needs to be placed, to provide the 

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most effective post-surgical analgesia. 

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Because EXPAREL encapsulates 
bupivacaine in liposomes, it stays 

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more precisely where it is injected 
and does not diffuse through the 

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tissues as readily as traditional 
bupivacaine. 

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With this in mind, for this procedure, 
I expanded 20 mL's of EXPAREL to a 

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total volume of 150 mL's by adding 
30 mL's of 0.25% bupivacaine and 

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100 mL's of normal saline. 

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These markings indicate the size of 
the planned incision to excise skin, 

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scar, and soft tissue with a planned 
inverted T closure. 

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First, I infiltrate the skin and 
subdermal layer prior to the initial 

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incision, as can be seen here. 

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The infiltration is best performed just 
lateral to the planned incision site. 

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When using EXPAREL, it is best to 
use a series of injections to 

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thoroughly cover the surgical area. 

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The infiltration wheel in the skin 
should overlap to be sure that there 

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are no gaps in a local anesthetic coverage. 

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Alternatively, if desired, the skin and 
subdermal infiltration can be 

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performed just prior to skin closure. 

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This is especially appropriate, if 
additional skin and soft tissue is 

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planned to be resected prior to 
wound closure. 

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By dissecting laterally in the retro 
rectus space, anterior to the posterior 

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fascia, the neurovascular bundles can 
be visualized traversing from the 

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transversus abdominis posteriorly 
through the rectus muscle anteriorly. 

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I infiltrate just medial to the 
neurovascular bundles to provide a 

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thorough field block and to provide 
hydro dissection in the plane 

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between the transversus abdominis 
and the peritoneum. 

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This will produce analgesic coverage 
for the nerves of the peritoneum as 

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well as the neurovascular bundles of 
the abdominal wall. 

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Again, the infiltration bubbles should 
overlap to prevent gaps in the 

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anesthetic effect. 

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Next, I perform a similar field block 
on the contralateral side of the 

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abdominal wall. 

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Once the field blocks are completed 
bilaterally, the transversus abdominis 

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release is performed by transecting 
the transversus abdominis vertically, 

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just medial to the neurovascular bundles. 

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The infiltration hydro dissection 
allows for easier separation of the 

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transversus abdominis from the 
peritoneum to facilitate the 

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transversus release, which could 
potentially decrease the likelihood of 

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damaging the peritoneum during 
the dissection. 

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When performing surgical site 
infiltration with EXPAREL,

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the following clinical practices
and techniques are utilized. 

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EXPAREL should be administered 
using a 25-gauge or larger bore needle,

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so as to not cause disruption 
of the liposomes. 

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For the cases I have performed, I 
usually use a 21 or 22-gauge 

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needle that is 1.5 inches in length. 

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It is important to ensure that all 
layers of the surgical incision are 

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infiltrated in a controlled and 
meticulous manner and that 

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EXPAREL is injected within the 
tissue planes. 

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When performing an abdominal wall 
reconstruction under direct 

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visualization, I insert the needle 
approximately 0.5 to 1 cm into the 

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peritoneum, the musculofascial or 
the subdermal tissue planes. 

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Proper infiltration technique with 
EXPAREL involves using a 

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continuous motion, fanning 
technique, commonly referred to as 

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a moving needle technique. 

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EXPAREL is injected while slowly 
withdrawing the needle in order to 

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adequately infiltrate all layers of the 
skin, the musculus fascia and the 

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peritoneum and to reduce the risk of 
intravascular injection. 

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The volume of EXPAREL that should 
be used is based on the size of 

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the surgical site. 

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To accommodate larger surgical 
sites, a 20 mL vial of EXPAREL 

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can be expanded with normal saline 
or lactated Ringer's solution, up to a 

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total volume of 300 mL's. Typically, 
I use a volume based on a calculation 

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of 0.5 to 1 mL for every 1 to 1.5 cm 
of surgical incision per layer. 

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For a transverse incision, such as a 
pfannenstiel incision in an open 

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abdominal hysterectomy, which is 
typically 12 to 15 cm's long, I would 

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use a total volume of 60 mL's with 
20 mL's injected into the peritoneal plane, 

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20 mL's injected into the musculofascial 
plane, and 20 mL's injected into the 

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subdermal plane. 

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For an abdominal wall reconstruction 
using the transversus abdominis 

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release approach, as demonstrated 
in this video, the total volume of

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injection would be 100 to 150 mL's 
because of the larger area

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of dissection. 

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In order to achieve faster onset of 
analgesia and improve pain relief 

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immediately post-surgery, EXPAREL 
can be admixed with bupivacaine 

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hydrochloride, provided that the ratio 
of the mg dose of bupivacaine 

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hydrochloride solution to EXPAREL 
does not exceed 1 to 2. 

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As noted earlier, I prepare an 
injection solution using 20 mL's of 

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EXPAREL, combined with 30 mL's of 
0.25% bupivacaine and 100 mL's of 

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normal saline to achieve a total 
volume of 150 mL's. 

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So, we have continued to try to learn 
how to improve our infiltration 

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techniques because clearly if you 
don't get the nerves anesthetized 

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well and you don't get the broad 
distribution across your whole 

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surgical field, you can have less than 
optimal outcomes. 

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So we have tried to learn and adapt 
the technique and one of the issues 

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is it does require some dedication 
to infiltrating across all of the

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planes, from the subdermal plane 
and then peritoneum and the 

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neurovascular bundles. 

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And it does require a little bit of extra 
time, but even applying the attention 

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to detail and sometimes like today, I 
re-infiltrated at the transversus 

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abdominis after we placed the mesh, 
just to try to get the best chance 

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possible for a complete block. 

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But as you saw today, it added only 
a few minutes to the operation, so it's 

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not an extensive increase in 
operative time. Some of our other 

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process improvements to try to 
eliminate use of drains where we 

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use quilting sutures, that's added a 
lot more to our operative time, but 

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we still do that because of the 
benefit to the patient.