What is the best course of treatment for a patient with right abdominal wall pain following a right lower lobe segmentectomy?

Management of Right Abdominal Wall Pain Following Right Lower Lobe Segmentectomy

Implement a multimodal analgesia strategy combining abdominal wall nerve blocks (TAP or rectus sheath block) with local wound infusion, NSAIDs, and acetaminophen, while minimizing opioid use to optimize pain control and functional recovery. 1

Initial Assessment and Diagnosis

Before initiating treatment, confirm the pain is musculoskeletal abdominal wall pain rather than intra-abdominal pathology:

• Perform Carnett test: Have the patient tense abdominal muscles while you palpate the painful area. Pain that stays the same or worsens indicates abdominal wall pain rather than visceral pathology 2
• Identify a localized tender spot at the lateral edge of the rectus abdominis or along the surgical incision site, which is characteristic of nerve entrapment or incisional pain 2
• Rule out surgical complications: If fever, signs of infection, or systemic symptoms are present, obtain CT abdomen/pelvis with IV contrast to exclude abscess, hematoma, or other postoperative complications 1

Primary Treatment Strategy: Regional Anesthesia Techniques

Abdominal wall blocks are the cornerstone of treatment for moderate-to-severe postoperative abdominal wall pain (NRS >6). 1

Nerve Block Options

• TAP (Transversus Abdominis Plane) block is safe and effective, producing statistically significant VAS reduction at 12 hours post-procedure 1
• Rectus sheath block is a viable alternative to TAP block with equivalent efficacy 1
• Use ropivacaine with dexamethasone as the preferred combination, as perineural dexamethasone improves postoperative analgesia quality and duration 1

Local Wound Infusion

• Consider continuous local wound infusion catheters for persistent pain, which significantly decrease VAS scores at rest and with activity at 6,12,24, and 48 hours 1
• These catheters consistently reduce opioid requirements (both rescue doses and total dose) without increasing surgical site infection risk 1
• Plan catheter removal with appropriate transition analgesia to prevent rebound pain 1

Multimodal Pharmacologic Approach

Combine regional techniques with systemic non-opioid analgesics to maximize pain control while minimizing opioid-related side effects. 1, 3

• NSAIDs as first-line systemic therapy for their anti-inflammatory and analgesic properties 3
• Acetaminophen scheduled dosing (not PRN) as part of the multimodal regimen 1
• Short-acting opioids only as rescue medication, given by nurses or via PCA, not as primary therapy 3
• Avoid long-acting opioids which delay ambulation, impair bowel function, and negatively affect mental status 4

Diagnostic Injection for Nerve Entrapment

If pain persists despite initial management and localizes to a specific trigger point:

• Perform diagnostic/therapeutic injection with local anesthetic (with or without corticosteroid) at the point of maximal tenderness 2
• 50% pain improvement post-injection confirms the diagnosis of anterior cutaneous nerve entrapment syndrome 2
• Overall response rate is 70-99% for local injection treatment of nerve entrapment 2
• Point-of-care ultrasonography can guide injections and rule out other abdominal wall pathologies like hernias 2

Refractory Pain Management

For pain requiring more than two injections or failing conservative management:

• Surgical neurectomy generally resolves pain in refractory anterior cutaneous nerve entrapment syndrome 2
• Re-evaluate for alternative diagnoses including incisional hernia, myofascial pain, or chronic nerve injury 5

Critical Pitfalls to Avoid

• Do not assume all postoperative pain is "normal": Persistent localized abdominal wall pain months after surgery suggests nerve entrapment or other specific pathology requiring targeted treatment 5, 2
• Do not order extensive imaging for clearly localized abdominal wall pain with positive Carnett test and no systemic symptoms, as this leads to expensive, nondiagnostic workups 2
• Do not rely on opioids as first-line therapy: They are particularly problematic in abdominal surgery, delaying ambulation and bowel function recovery 4, 3
• Do not use epidural analgesia as first-line: This has become a second-line option, reserved for specific patient morbidities or surgical requirements 3

Patient Education and Reassurance

• Reassurance and education about the benign nature of abdominal wall pain (once serious pathology is excluded) can be therapeutic 2
• Set realistic expectations about pain trajectory and the effectiveness of nerve blocks and local injections 1