proctology = ideal field for major ambulatory surgery (MAS)feasibility for every proctological disease in the elective setting

nerve blocks in proctology is not “a new thing”

2 admissions

23 complications (0.6%)

“local anaesthesia and posterior perineal block”

submucosa below the dentate lineintersphinteric planeexternal an parallel to the AES

local anaesthesia in proctology

what do we mean when we say “nerve blocks in proctology”?

blocking the PUDENDAL (internal) NERVES2-S4 branches of sacral plexus

50% sensitiveperineum and external genitals skin

(scrotum, labia, perineum y anus)

20% motor(AES, UES, levator ani, bulbocavernosus and

ischiocavernosus and deep+superficial perineum muscles)

30% vegetative(erection and sensation/need of

micturition)

two different levels of blockade

TRUNK : at the ischial spine, before any divisionPERIPHERAL : just perianal or ischiorectal 360º (only perineal nerve)

two different levels of blockade

TRUNK : at the ischial spine, before any divisionPERIPHERAL : just perianal or ischiorectal 360º (only perineal nerve)

nerve blocks in proctology may be used as…..

anaesthetical technique of choicelow dose of midazolam / fentanil

+ EMLA

+ pudendal blockade before surgery (central, with nerve stimulation or not, or peripheral)

complement to reduce postoperative pain and the need of analgesic treatment surgery under general / spinal anaesthesia

+block performed when surgery is finished (central, with nerve stimulation or not, or peripheral)

trunk blockade and the use of nerve stimulator

ischial spine is always the reference

20-ml syringe with mixture of local anaesthetic & 10-cm IM needlecross between upper margin of anus and ischial spine for punction

stimulating current of 2-4 mA is used until responselowering of the current to a minimum and infiltration of anesthetic

Prospective RCT series, 50/50 patients

hemorrhoidectomy under spinal anaesthesia

trunk bilateral PN block Bupivacaine / not (nerve stimulator)

no urine retention for both groups

MEAN DURATION OF POSTOPERARIVE ANALGESIA: 23.8

vs 3.6 HOURS

complement to reduce postoperative pain and the need of analgesic treatment

surgery under spinal anaesthesia+

block performed when surgery is finished (central with nerve stimulation)

WORKS!!!

complement to reduce postoperative pain and the need of analgesic treatment

surgery under SPINAL anaesthesia+

block performed when surgery is finished (central with nerve stimulation)

WORKS!!!complement to reduce postoperative pain and the need of analgesic treatment

surgery under GENERAL anaesthesia

+block performed when surgery is finished (central with nerve stimulation)

WORKS!!!

less urinary retention

higher patients discharging as MAS

lower pain in routine

faster return to normal activities

higher degree of satisfaction

patients in the group of PN blockade had…….

VAS of pain was significatively lower for rest, sitting and walking in the group of patients operated

with pudendal block

anaesthetical technique of choicelow dose of midazolam / fentanil

+ EMLA

+ pudendal blockade before surgery (central with nerve stimulation)

WORKS!!!

9.1 vs. 3.1 h.

urinary retention 7.5% vs. 69.6%

anaesthetical technique of choicelow dose of midazolam / fentanil

+ EMLA

+ pudendal blockade before surgery (peripheral)

WORKS!!!

pudendal block (peripheral) is better than spinal anaesthesia (being independent of the use of Ligasure or diathermy)

anaesthetical technique of choicelow dose of midazolam / fentanil

+ EMLA

+ pudendal blockade before surgery (peripheral)

WORKS!!!

prospective RC study, 120 patientslocal perianal vs trunk blockade of pudendal nerve (no

stimulator) as the only anaesthetic technique

Trunk blockade of pudendal nerve is better than peripheral (better VAS in first p.o. +8h & higher % of discharge in MAS)

infiltrations / pudendal nerve blockades are strongly recommended in order to control postoperative pain and favour the MAS setting

There are scientific evidences of adequate level in the literature reporting the effectiveness of the blockade of pudendal nerves in proctology

Although blocking the main trunk seems more effective, the most feasible technique is peripheral blockade just in the ischiorectal fosa o purely perianal. Both of them are easy to

perform and have a very low rate of potential complications

Its use will decrease the postoperative pain and the need of analgesic medication in the postoperative period; then, the most part of the patients will be properly treated in major

ambulatory surgery programs without hospital admission

We, the surgeons, are in the need to help as much as we can to patients who need an hemorrohoidal or any proctological operation, and avoiding pain in any way is a key factor.

CONCLUSIONS