This video shares instructions and visualization on performing
the infiltration of EXPAREL at the time of closure of a
pfannenstiel incision, most commonly used at the time of
cesarean section. This video will review the steps of local
infiltration.
In this procedure Dr. Cherot determined a total volume of
80 mLs would be needed to cover the surgical site. She
admixed 20 mLs of EXPAREL with 24 mLs of half percent
bupivacaine HCL to provide early onset analgesia and
bridge the time to onset of the long-acting local analgesia
provided by EXPAREL, and further expanded the volume
with 36 mLs of normal saline. Dr. Cherot used a 22-gauge
needle and four 20 mL syringes to complete these injections.
Dr. Cherot infiltrates 40 mLs of the EXPAREL admixture
bilaterally into the interior rectus abdominis muscle and rectus
sheath. She infiltrated 20 mLs of the admixture on each side,
injecting parallel to the surgical plane in a fan-like pattern.
Dr. Cherot delivered approximately 5 mLs deep into
the tissue with each injection to ensure optimal coverage of the
area. She infiltrated as she moved the needle to optimize
coverage with the admixture. She then re-approximated the
fascia before continuing with the remaining infiltration steps.
This woman, unfortunately has got a little fat pad there, but the
lipid layer is not where you want to be, but you truly want to see
and you can see it starting to swell nicely. And it looks almost
dilute, right? Like her rectus muscle is just getting infiltrated,
which is exactly what you want. And again, going as lateral and
trying to go south to get into the ilioinguinal nerve, which is
further south, right? So again, withdrawing. And I’m not going
into the abdomen, I’m staying in the rectus muscle. Really
important to distinguish that. See that swell up? Beautiful!
Love that plane. Nice. That was awesome. Lateral, right?
Withdraw, stay in the rectus muscle and inject. There you go,
that actually infiltrated nicely. Starts to leak, you’ve
know you got to redirect. The same idea, withdraw.
Plane. You're not parallel to the tissue itself. Same idea. Hoping
that this starts to swell. That it will, and you're not in the
abdomen, you’re really parallel. Dr. Cherot infiltrated 20 mLs of
the EXPAREL admixture bilaterally from the corners of
the fascial incision site. She infiltrated in a fan-like
pattern, delivering 3 to 4 mLs of the admixture with each
injection for a total of 10 mLs on each side. Dr. Cherot infiltrated
above and below the fascia and into the subcutaneous tissue,
parallel and along the natural, lateral descending curvature of
the fascial plane. She infiltrated out toward the iliohypogastric
and ilioinguinal nerves as well as the obliques or aponeurosis
begins to form the rectus sheath.
So again, same idea. So things I wouldn't want to see, for
instance, would be, coming through the skin like that, which
you can see this little poke here. Not what I want to do. I want to
be a little deeper than that. Other things you don't want to do,
would be going to deep.
You don't need to be at that angle. Again it’s parallel with the
incision itself, um and as lateral as you can. Because again,
you’re trying to get those nerves and the branching point.
So another 10 ccs being injected out in that fan-like.
You will sometimes be so close to the skin, especially on
somebody super skinny, that you might actually feel where
you’ve injected a little, you know, just in the sub Q. That
will, as it gets absorbed, go away. And is not a problem.
And again, same thing, you want to be careful not to hit any
vessels, you’re withdrawing back and injecting.
Same idea, going out lateral, withdrawing and then injecting.
In this final step, Dr. Cherot performed bilateral field blocks,
infiltrating two fingerbreadths superior or medial to the
anterior superior iliac crest. She infiltrated 10 mLs of the
EXPAREL admixture on the right and left side of the patient,
perpendicular to the surgical plane, making sure to deliver
the admixture deep into the abdominal wall. This step
provides a field block of the ilioinguinal nerves, addressing
pain from any innervation closer to the incision. If preferred, the
surgeon can also choose to infiltrate the remaining 20 mLs
of the admixture along the incision above and below the
fascia and into the subcutaneous tissue.
So anterior iliac spine, right? Two fingerbreadths above,
right? You’re going to realize this woman is not very thick.
Average for New Jersey’s a little bigger than that.
Two fingerbreadths above. You want to do where you think you would
put a port for a laparoscopic, right? The more medial,
I’m worrying about my, um epigastric, so you want to be
very careful of that. So, again, I’m not bearing this off but going
halfway down, right? And I’m going to put about 5 ccs right there.
Can’t count upside down. And then I’m going to start to
withdraw slightly, but continue to put another couple ccs. A little
more. And again, the whole point is I'm really trying to get at
nerve endings. And that’s it. And if you just want to, out lateral
here was the major ones we did with 10 ccs. You could take
another, you know, 5 to 10 up here. Another 5 to 10 even more
medial or along the line of the, of the incision which I think
I showed when I was doing that before.