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Majaliwa Shabani,1 Seydina Alioune Beye,2,* Abdoulaye Traore,3 Pablo Echave,4,* Xavier Raingeval,5,* Daouda Coulibaly,6 Sophie Crespo7,* 1Health_unit, International Committee of the Red Cross, Bamako, Mali; 2Anesthesia Department, Clinique Périnatale Mohamed VI, Bamako, Mali; 3Anesthesia Department, Hôpital Somine Dolo de Mopti, Mopti, Mali; 4Anesthesia Department, Université de Sherbrooke, Sherbrooke, Quebec, Canada; 5Association de Développement et de Recherche en Anesthésie Locorégionale Echoguidée (ADRALE), Paris, France; 6Surgery Department, Centre de Santé de Référence de Kidal, Kidal, Mali; 7Health Unit, International Committee of the Red Cross, Geneva, Switzerland*These authors contributed equally to this workCorrespondence: Majaliwa Shabani, Health Unit, International Committee of the Red Cross, HAMDALLAYE RUE 239, Postal Office Box: 58, Bamako, Mali, Email mshabani2001@gmail.comPurpose: The posterior femoral cutaneous nerve (PFCN) block is used in regional anesthesia for lower extremity surgery. This study introduces a new ultrasound-guided technique called the “Gluteus-Deep Investing Fascia compartment Block (GDIF block)“ for blocking the PFCN. This approach involves injecting local anesthetic into the potential space between the gluteus maximus muscle and the deep investing fascia, named the ‘Gluteus Deep Investing Fascia Compartment’. The study discusses the anatomical and sonographic features crucial for identifying this compartment and explores the potential benefits of this approach for achieving effective PFCN block. Additionally, it examines the clinical application of the GDIF block for PFCN block as part of the Complete Lower Extremity Fascia Tri-compartment Block technique, named ”CLEFT Block.” This technique combines the suprainguinal fascia iliaca block with GDIF compartment block for PFCN and a sciatic nerve block as exclusive anesthesia technique.Patients and Methods: Nine patients with weapon-related lower limb injuries underwent surgery at district hospitals supported by the International Committee of the Red Cross. Between October and December 2023, seventeen above-knee procedures were performed for the nine patients using the GDIF block as part of a CLEFT block technique. Anesthesia was performed with a CLEFT block technique using a volume ratio of 1:1 of 1% lidocaine and 0.5% levobupivacaine.Results: The GDIF block technique for PFCN blockade was performed successfully in all patients without complications, achieving complete PFCN blockade. The CLEFT block technique proved effective as the sole anesthetic technique for seventeen above-knee procedures. All surgeries were completed successfully without additional pain medication or conversion to general anesthesia.Conclusion: The GDIF block appears to be a promising technique for anesthetic management, alone or as part of the CLEFT block. Further research with a larger patient population is necessary to validate these findings.Keywords: posterior femoral cutaneous nerve block, deep investing fascia, sciatic nerve block, gluteal deep investing fascia compartment block, GDIF block, CLEFT block

Majaliwa Shabani,1,* Seydina Alioune Beye,2,* Abdoulaye Traore,3,* Xavier Raingeval,4,* Daouda Coulibaly,5,* Sophie Crespo6,* 1Health_Unit, International Committee of the Red Cross, Bamako, Mali; 2Anesthesia Department, Clinique Périnatale Mohamed VI, Bamako, Mali; 3Anesthesia Department, Hôpital Somine Dolo de Mopti, Mopti, Mali; 4Association de Développement et de Recherche en Anesthésie Locorégionale Echoguidée, Paris, France; 5Surgery Department, Centre de Santé de Référence de Kidal, Kidal, Mali; 6Health Unit, International Committee of the Red Cross, Geneva, Switzerland*These authors contributed equally to this workCorrespondence: Majaliwa Shabani, Health Unit, International Committee of Red Cross (ICRC), Rue 239, Hamdallaye /ACI2000 – B.P. 58, Bamako, Mali, Email mshabani2001@gmail.comPurpose: The management of unstable patients with weapon-wounded lower limb vascular injuries presents significant anesthetic challenges. Regional anesthesia blocks, which combine lumbar and sacral plexus blocks, or their respective branches, minimize systemic effects and are deemed appropriate for high-risk patients requiring lower limb surgery. This case series aims to share our preliminary experiences with a combined anesthetic technique—sciatic nerve (SN), posterior femoral cutaneous nerve (PFCN), and supra-inguinal fascia iliaca (SIFI) blocks —in patients sustaining weapon wounds and undergoing lower limb vascular injury repair in austere environments.Patients and Methods: Seven patients with lower limb vascular injuries resulting from weapons who required surgery at district hospitals supported by the International Committee of the Red Cross were included in this study. Included patients underwent surgery for vascular repair and debridement using a combined nerve block technique involving the SN, PFCN, and SIFI blocks between May and December 2023. The blocks were administered using a 1:1 mixture of 1% lidocaine and 0.5% levobupivacaine.Results: The combined block technique for the Sciatic Nerve (SN), Posterior Femoral Cutaneous Nerve (PFCN), and the Supra-Inguinal Fascia Iliaca (SIFI) were performed without complications in all patients. Three of the patients received light sedation prior to the initiation of the block procedure. All surgeries were completed successfully without the need for additional analgesics or conversion to general anesthesia.Conclusion: The combined block technique for the Sciatic Nerve (SN), Posterior Femoral Cutaneous Nerve (PFCN), and the Supra-Inguinal Fascia Iliaca (SIFI) appears to be a safe anesthetic option for unstable or high-risk patients requiring lower limb surgery. Further research with a larger cohort is necessary to validate our findings and to potentially standardize this approach.Keywords: war surgery, posterior femoral cutaneous nerve block, anesthesia in austere environments