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

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”
nerve blocks in proctology is not “a new thing”
proctology = ideal field for major ambulatory surgery (MAS) feasibility for every proctological disease in the

2 admissions

23 complications

(0.6%)

“local anaesthesia and posterior perineal block”

local anaesthesia in proctology submucosa below the dentate line intersphinteric plane external an parallel to the
local anaesthesia in proctology submucosa below the dentate line intersphinteric plane external an parallel to the
local anaesthesia in proctology submucosa below the dentate line intersphinteric plane external an parallel to the

local anaesthesia in proctology

local anaesthesia in proctology submucosa below the dentate line intersphinteric plane external an parallel to the

submucosa below the dentate line intersphinteric plane

external an parallel to the AES

what do we mean when we say “nerve blocks in proctology”? blocking the PUDENDAL (internal) NERVE

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

blocking the PUDENDAL (internal) NERVE S2-S4 branches of

what do we mean when we say “nerve blocks in proctology”? blocking the PUDENDAL (internal) NERVE

sacral plexus

50% sensitive

perineum and external genitals

skin (scrotum, labia, perineum y anus)

20% motor

(AES, UES, levator ani, bulbocavernosus and ischiocavernosus and deep+superficial perineum muscles)

two different levels of blockade TRUNK : at the ischial spine, before any division PERIPHERAL :

two different levels of blockade

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

two different levels of blockade TRUNK : at the ischial spine, before any division PERIPHERAL :
two different levels of blockade TRUNK : at the ischial spine, before any division PERIPHERAL :
two different levels of blockade TRUNK : at the ischial spine, before any division PERIPHERAL :

two different levels of blockade

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

two different levels of blockade TRUNK : at the ischial spine, before any division PERIPHERAL :
nerve blocks in proctology may be used as… .. anaesthetical technique of choice low dose of

nerve blocks in proctology may be used as… ..

anaesthetical technique of choice

low 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 +

trunk blockade and the use of nerve stimulator ischial spine is always the reference

trunk blockade and the use of nerve stimulator

trunk blockade and the use of nerve stimulator ischial spine is always the reference
trunk blockade and the use of nerve stimulator ischial spine is always the reference

ischial spine is always the reference

20-ml syringe with mixture of local anaesthetic & 10-cm IM needle cross between upper margin of
20-ml syringe with mixture of local anaesthetic & 10-cm IM needle cross between upper margin of
20-ml syringe with mixture of local anaesthetic & 10-cm IM needle cross between upper margin of
20-ml syringe with mixture of local anaesthetic & 10-cm IM needle cross between upper margin of

20-ml syringe with mixture of local anaesthetic & 10-cm IM needle cross between upper margin of anus and ischial spine for punction stimulating current of 2-4 mA is used until

Prospective RCT series, 50/50 patients hemorrhoidectomy under spinal anaesthesia trunk bilateral PN block Bupivacaine / not
Prospective RCT series, 50/50 patients hemorrhoidectomy under spinal anaesthesia trunk bilateral PN block Bupivacaine / not

Prospective RCT series,

50/50 patients

hemorrhoidectomy under

spinal anaesthesia

trunk bilateral PN block

Bupivacaine / not (nerve

stimulator)

MEAN DURATION OF

no urine retention for both

POSTOPERARIVE

groups

ANALGESIA: 23.8 vs 3.6

HOURS

Prospective RCT series, 50/50 patients hemorrhoidectomy under spinal anaesthesia trunk bilateral PN block Bupivacaine / not
complement to reduce postoperative pain and the need of analgesic treatment surgery under spinal anaesthesia +

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 +

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)

patients in the group of PN blockade had……. less urinary retention higher patients discharging as MAS
patients in the group of PN blockade had……. less urinary retention higher patients discharging as MAS
patients in the group of PN blockade had……. less urinary retention higher patients discharging as MAS
patients in the group of PN blockade had……. less urinary retention higher patients discharging as MAS

patients in the group of PN

blockade had…….

less urinary

retention

patients in the group of PN blockade had……. less urinary retention higher patients discharging as MAS

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……. less urinary retention higher patients discharging as MAS
patients in the group of PN blockade had……. less urinary retention higher patients discharging as MAS
patients in the group of PN blockade had……. less urinary retention higher patients discharging as MAS
VAS of pain was significatively lower for rest, sitting and walking in the group of patients
VAS of pain was significatively lower for rest, sitting and walking in the group of patients
VAS of pain was significatively lower for rest, sitting and walking in the group of patients

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

anaesthetical technique of choice low dose of midazolam / fentanil + EMLA + pudendal blockade before

anaesthetical technique of choice

low 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%
9.1 vs. 3.1 h. urinary retention 7.5% vs. 69.6%

9.1 vs. 3.1

h.

urinary retention 7.5% vs.

9.1 vs. 3.1 h. urinary retention 7.5% vs. 69.6%

69.6%

anaesthetical technique of choice low dose of midazolam / fentanil + EMLA + pudendal blockade before

anaesthetical technique of choice

low 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
pudendal block (peripheral) is better than spinal anaesthesia (being independent of the use of
pudendal block (peripheral) is better than spinal anaesthesia (being independent of the use of

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

anaesthetical technique of choice low dose of midazolam / fentanil + EMLA + pudendal blockade before

anaesthetical technique of choice

low dose of midazolam / fentanil + EMLA + pudendal blockade before surgery (peripheral)

WORKS!!!

prospective RC study, 120 patients local perianal vs trunk blockade of pudendal nerve (no stimulator) as
prospective RC study, 120 patients local perianal vs trunk blockade of pudendal nerve (no stimulator) as

prospective RC study, 120 patients local perianal vs trunk blockade of pudendal nerve (no stimulator) as the only anaesthetic technique

prospective RC study, 120 patients local perianal vs trunk blockade of pudendal nerve (no stimulator) as
prospective RC study, 120 patients local perianal vs trunk blockade of pudendal nerve (no stimulator) as

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

infiltrations / pudendal nerve blockades are strongly recommended in order to control postoperative pain
infiltrations / pudendal nerve blockades are strongly recommended in order to control postoperative pain
infiltrations / pudendal nerve blockades are strongly recommended in order to control postoperative pain

infiltrations / pudendal nerve blockades are strongly recommended in order to control postoperative pain

CONCLUSIONS There are scientific evidences of adequate level in the literature reporting the effectiveness of the

CONCLUSIONS

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.