A 53-year-old woman presented with an iatrogenic right hepatic artery pseudoaneurysm after a laparoscopic cholecystectomy. Approximately 1 year after the cholecystectomy, liver transaminases were elevated, and she complained of recurrent "crampy" right upper quadrant pain that radiated posteriorly to her back. Imaging studies demonstrated an aneurysm or pseudoaneurysm of the hepatic artery at the porta hepatis, with possible infiltration into the parenchyma between the right and left lobes of the liver. Selective celiac arteriography showed a 90% stenosis of the right hepatic artery with a large pseudoaneurysm arising from the stenotic segment. This was treated with a 3- x 16-mm stent graft (Jostent; Abbott Vascular, Temecula, Calif) with good result. The completion arteriogram showed wide patency of the stent graft with total exclusion of the pseudoaneurysm. Follow-up serial duplex scans up to 40 months after the procedure showed no evidence of residual pseudoaneurysm and wide patency of the stent graft, with no evidence of focal velocity changes in the right hepatic artery. The patient continues to do well clinically.

Regional and neuraxial anesthesia for pain management after breast surgery is not widely used despite data showing improved postoperative pain control and patient satisfaction scores. We report a case of a 61-year-old woman who underwent bilateral mastectomies, and received postoperative analgesia via pectoral nerves 1 and 2 nerve blocks. This case highlights a previously undescribed technique of prolonged postoperative pain control by intraoperative placement of pectoral nerves 1 and 2 regional anesthesia catheters under direct visualization. Intraoperative placement has the potential benefits of more accurate plane targeting, time saving, and widening the scope of use to practitioners are not trained in the ultrasound guided technique. We also present a review of the regional block techniques and present a preliminary algorithm for the selection of block method in breast surgery.

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Caudal epidural anesthesia in pediatric patients was first described in 1933 as a replacement for general anesthesia in 83 children undergoing transurethral surgery, and since that time it has been shown to be useful in a variety of surgeries. The popularity of this block stems from its efficacy, simplicity, speed, and relative safety. The caudal approach to the epidural space can be used for the administration of local anesthetic and adjunct medications for either surgical anesthesia or postoperative analgesia. This technique is most commonly applied to surgical procedures occurring below the umbilicus and is frequently used as a single injection technique to be performed after induction of general anesthesia and before surgical incision for augmentation of general anesthesia and postoperative pain control. For longer procedures, a catheter can be placed to facilitate repeat dosing at the conclusion of surgery. Alternatively, more cephalad dermatomes can be anesthetized with an epidural catheter threaded to the desired level. The benefits of caudal epidural anesthesia extend beyond postoperative analgesia and include decreased intraoperative anesthetic requirements and a reduction in the neuroendocrine stress response to surgery.