title: Surgical Site Infiltration for Abdominal Surgery: A Novel Neuroanatomical-based Approach.
abstract: 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.
authors.affiliation: Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Tex.; Department of Plastic Surgery, Ohio State University Medical Center, Columbus, Ohio; Department of Surgery, Houston Methodist Hospital, Houston, Tex.; Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tenn.; Department of Obstetrics and Gynecology and Geriatrics, University of Oklahoma College of Medicine, Oklahoma City, Okla.; and Department of Surgery, Houston Methodist Institute for Technology, Innovation, and Education, Houston, Tex.
authors.forename: Girish P
authors.initials: GP
authors.lastname: Joshi
authors.affiliation: Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Tex.; Department of Plastic Surgery, Ohio State University Medical Center, Columbus, Ohio; Department of Surgery, Houston Methodist Hospital, Houston, Tex.; Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tenn.; Department of Obstetrics and Gynecology and Geriatrics, University of Oklahoma College of Medicine, Oklahoma City, Okla.; and Department of Surgery, Houston Methodist Institute for Technology, Innovation, and Education, Houston, Tex.
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Janis
authors.affiliation: Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Tex.; Department of Plastic Surgery, Ohio State University Medical Center, Columbus, Ohio; Department of Surgery, Houston Methodist Hospital, Houston, Tex.; Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tenn.; Department of Obstetrics and Gynecology and Geriatrics, University of Oklahoma College of Medicine, Oklahoma City, Okla.; and Department of Surgery, Houston Methodist Institute for Technology, Innovation, and Education, Houston, Tex.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Haas
authors.affiliation: Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Tex.; Department of Plastic Surgery, Ohio State University Medical Center, Columbus, Ohio; Department of Surgery, Houston Methodist Hospital, Houston, Tex.; Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tenn.; Department of Obstetrics and Gynecology and Geriatrics, University of Oklahoma College of Medicine, Oklahoma City, Okla.; and Department of Surgery, Houston Methodist Institute for Technology, Innovation, and Education, Houston, Tex.
authors.forename: Bruce J
authors.initials: BJ
authors.lastname: Ramshaw
authors.affiliation: Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Tex.; Department of Plastic Surgery, Ohio State University Medical Center, Columbus, Ohio; Department of Surgery, Houston Methodist Hospital, Houston, Tex.; Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tenn.; Department of Obstetrics and Gynecology and Geriatrics, University of Oklahoma College of Medicine, Oklahoma City, Okla.; and Department of Surgery, Houston Methodist Institute for Technology, Innovation, and Education, Houston, Tex.
authors.forename: Mikio A
authors.initials: MA
authors.lastname: Nihira
authors.affiliation: Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Tex.; Department of Plastic Surgery, Ohio State University Medical Center, Columbus, Ohio; Department of Surgery, Houston Methodist Hospital, Houston, Tex.; Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tenn.; Department of Obstetrics and Gynecology and Geriatrics, University of Oklahoma College of Medicine, Oklahoma City, Okla.; and Department of Surgery, Houston Methodist Institute for Technology, Innovation, and Education, Houston, Tex.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Dunkin