I am Bruce Ramshaw.
I'm the Professor and Chair of Surgery at the University of
Tennessee in Knoxville.
I work with the University of Tennessee Medical Center and
Graduate School of Medicine.
Today we had a patient with an abdominal wall reconstruction redo.
She'd had multiple previous operations, the most recent was an
open component separation with an onlay with a biologic mesh.
Unfortunately, she developed chronic pain and distention and a diastasis.
The biologic mesh had stretched, and she had some eventration and
we did another abdominal wall reconstruction using a synthetic
mesh that's made out of randomly oriented microfibers of polypropylene.
Hopefully more biocompatible and placed in a retro rectus position
using a transversus abdominis release.
And so, we were able to get a reconstruction with a lot more
integrity less likely to stretch and break down than what she had had
in the past.
I think like most surgeons, and our hernia team we were relying heavily
on the opioid pain medications. We saw the benefit, being the patient
didn't experience pain, but some of the negatives were, they weren't
able to take a deep breath, get up and move around.
They often were in and out of doziness and sleeping and often
they got nausea.
Part of the reason they couldn't get out of bed was because they were
nauseated and really couldn't move, had to keep the room dark, You know
had to keep aa pillow over their head.
And so, the opioids, although it made us feel better, the patient, I think
wasn't getting the optimal perioperative recovery and the
concepts of enhanced recovery and the ability to get up and move and
eat and do things that we want to see patients able to do quicker.
That wasn't being achieved with an opioid primary strategy.
The long-acting local anesthetic we have started to use is as part of our
continuous quality improvement effort with our hernia program.
A few years ago, we saw the opportunity to try to decrease the
experience of pain.
I think what we're seeing in our program and across healthcare
is more of an attention to the patient perspective, the ability to see what
it's like to go through surgery and recovery and learn that you know
there are a lot of things we can do better when you look it up from the
patients' perspective and pain is one of the major things that patients are
afraid of.
They come in with a lot of anxiety, apprehension, especially if they've
had prior surgery and they've had a negative experience.
So, to be able to have a better strategy for pain control and to help
patients understand the opportunity to lessen the impact of opioids in
their preoperative care and recovery.
It's been part of our continuous quality improvement in terms of
trying to improve value to the patient.
Today I'm performing an abdominal wall reconstruction with a
transversus abdominis release approach.
When determining the most appropriate expansion volume to use
for any procedure with EXPAREL, it's important to consider the size of
the surgical site where the product needs to be placed, to provide the
most effective post-surgical analgesia.
Because EXPAREL encapsulates bupivacaine in liposomes, it stays
more precisely where it is injected and does not diffuse through the
tissues as readily as traditional bupivacaine.
With this in mind, for this procedure, I expanded 20 mL's of EXPAREL to a
total volume of 150 mL's by adding 30 mL's of 0.25% bupivacaine and
100 mL's of normal saline.
These markings indicate the size of the planned incision to excise skin,
scar, and soft tissue with a planned inverted T closure.
First, I infiltrate the skin and subdermal layer prior to the initial
incision, as can be seen here.
The infiltration is best performed just lateral to the planned incision site.
When using EXPAREL, it is best to use a series of injections to
thoroughly cover the surgical area.
The infiltration wheel in the skin should overlap to be sure that there
are no gaps in a local anesthetic coverage.
Alternatively, if desired, the skin and subdermal infiltration can be
performed just prior to skin closure.
This is especially appropriate, if additional skin and soft tissue is
planned to be resected prior to wound closure.
By dissecting laterally in the retro rectus space, anterior to the posterior
fascia, the neurovascular bundles can be visualized traversing from the
transversus abdominis posteriorly through the rectus muscle anteriorly.
I infiltrate just medial to the neurovascular bundles to provide a
thorough field block and to provide hydro dissection in the plane
between the transversus abdominis and the peritoneum.
This will produce analgesic coverage for the nerves of the peritoneum as
well as the neurovascular bundles of the abdominal wall.
Again, the infiltration bubbles should overlap to prevent gaps in the
anesthetic effect.
Next, I perform a similar field block on the contralateral side of the
abdominal wall.
Once the field blocks are completed bilaterally, the transversus abdominis
release is performed by transecting the transversus abdominis vertically,
just medial to the neurovascular bundles.
The infiltration hydro dissection allows for easier separation of the
transversus abdominis from the peritoneum to facilitate the
transversus release, which could potentially decrease the likelihood of
damaging the peritoneum during the dissection.
When performing surgical site infiltration with EXPAREL,
the following clinical practices and techniques are utilized.
EXPAREL should be administered using a 25-gauge or larger bore needle,
so as to not cause disruption of the liposomes.
For the cases I have performed, I usually use a 21 or 22-gauge
needle that is 1.5 inches in length.
It is important to ensure that all layers of the surgical incision are
infiltrated in a controlled and meticulous manner and that
EXPAREL is injected within the tissue planes.
When performing an abdominal wall reconstruction under direct
visualization, I insert the needle approximately 0.5 to 1 cm into the
peritoneum, the musculofascial or the subdermal tissue planes.
Proper infiltration technique with EXPAREL involves using a
continuous motion, fanning technique, commonly referred to as
a moving needle technique.
EXPAREL is injected while slowly withdrawing the needle in order to
adequately infiltrate all layers of the skin, the musculus fascia and the
peritoneum and to reduce the risk of intravascular injection.
The volume of EXPAREL that should be used is based on the size of
the surgical site.
To accommodate larger surgical sites, a 20 mL vial of EXPAREL
can be expanded with normal saline or lactated Ringer's solution, up to a
total volume of 300 mL's. Typically, I use a volume based on a calculation
of 0.5 to 1 mL for every 1 to 1.5 cm of surgical incision per layer.
For a transverse incision, such as a pfannenstiel incision in an open
abdominal hysterectomy, which is typically 12 to 15 cm's long, I would
use a total volume of 60 mL's with 20 mL's injected into the peritoneal plane,
20 mL's injected into the musculofascial plane, and 20 mL's injected into the
subdermal plane.
For an abdominal wall reconstruction using the transversus abdominis
release approach, as demonstrated in this video, the total volume of
injection would be 100 to 150 mL's because of the larger area
of dissection.
In order to achieve faster onset of analgesia and improve pain relief
immediately post-surgery, EXPAREL can be admixed with bupivacaine
hydrochloride, provided that the ratio of the mg dose of bupivacaine
hydrochloride solution to EXPAREL does not exceed 1 to 2.
As noted earlier, I prepare an injection solution using 20 mL's of
EXPAREL, combined with 30 mL's of 0.25% bupivacaine and 100 mL's of
normal saline to achieve a total volume of 150 mL's.
So, we have continued to try to learn how to improve our infiltration
techniques because clearly if you don't get the nerves anesthetized
well and you don't get the broad distribution across your whole
surgical field, you can have less than optimal outcomes.
So we have tried to learn and adapt the technique and one of the issues
is it does require some dedication to infiltrating across all of the
planes, from the subdermal plane and then peritoneum and the
neurovascular bundles.
And it does require a little bit of extra time, but even applying the attention
to detail and sometimes like today, I re-infiltrated at the transversus
abdominis after we placed the mesh, just to try to get the best chance
possible for a complete block.
But as you saw today, it added only a few minutes to the operation, so it's
not an extensive increase in operative time. Some of our other
process improvements to try to eliminate use of drains where we
use quilting sutures, that's added a lot more to our operative time, but
we still do that because of the benefit to the patient.