Surgical Site Infiltration for Abdominal Surgery

A Novel Neuroanatomical-Based Approach

Girish P. Joshi, MBBS, MD, FFARCSI; Jeffrey E. Janis, MD, FACS; Eric M. Haas, MD, FACS, FASCRS; Bruce J. Ramshaw, MD; Mikio A. Nihira, MD, MPH, FACOG, FACS; Brian J. Dunkin, MD


Plast Reconstr Surg Glob Open. 2016;4(12):e1181 

In This Article

Abstract and Introduction


Background: Provision of optimal postoperative analgesia should facilitate postoperative ambulation and rehabilitation. An optimal multimodal analgesia technique would include the use of nonopioid analgesics, including local/regional analgesic techniques such as surgical site local anesthetic infiltration. This article presents a novel approach to surgical site infiltration techniques for abdominal surgery based upon neuroanatomy.

Methods: Literature searches were conducted for studies reporting the neuroanatomical sources of pain after abdominal surgery. Also, studies identified by preceding search were reviewed for relevant publications and manually retrieved.

Results: Based on neuroanatomy, an optimal surgical site infiltration technique would consist of systematic, extensive, meticulous administration of local anesthetic into the peritoneum (or preperitoneum), subfascial, and subdermal tissue planes. The volume of local anesthetic would depend on the size of the incision such that 1 to 1.5 mL is injected every 1 to 2 cm of surgical incision per layer. It is best to infiltrate with a 22-gauge, 1.5-inch needle. The needle is inserted approximately 0.5 to 1 cm into the tissue plane, and local anesthetic solution is injected while slowly withdrawing the needle, which should reduce the risk of intravascular injection.

Conclusions: Meticulous, systematic, and extensive surgical site local anesthetic infiltration in the various tissue planes including the peritoneal, musculofascial, and subdermal tissues, where pain foci originate, provides excellent postoperative pain relief. This approach should be combined with use of other nonopioid analgesics with opioids reserved for rescue. Further well-designed studies are necessary to assess the analgesic efficacy of the proposed infiltration technique.


Enhanced recovery after surgery, which involves implementation of evidence-based multimodal procedure-specific perioperative care pathways, has been shown to improve postoperative outcome and reduce length of hospital stay.[1] One of the major elements of a successful program for enhanced recovery after surgery is the provision of optimal postoperative analgesia to facilitate ambulation and rehabilitation therapy.[2] An optimal multimodal analgesia technique would include the use of nonopioid analgesics with different mechanisms of action, with the aim of reducing the need for opioids.[2] Reduction in opioid requirements should reduce opioid-related adverse events, which have been shown to increase perioperative morbidity and delay ambulation and rehabilitation therapy.[2,3] An ideal multimodal analgesic technique would include local/regional analgesic techniques (i.e., neuraxial blocks [epidural and paravertebral analgesia], field blocks [e.g., transversus abdominis plane blocks and rectus sheath block], and surgical site infiltration) combined with acetaminophen and either a nonsteroidal antiinflammatory drug or a cyclooxygenase-2 selective inhibitor and also analgesic adjuncts such as single intraoperative dose dexamethasone.[2]

This article presents a novel approach to surgical site infiltration techniques for abdominal surgical procedures based upon neuroanatomy.