A Comparison of UGBRS Block and Local Infiltration

Laparoscopic appendectomy is a common procedure in pediatric surgery. For single incision
laparoscopic appendectomy (SILA), the laparoscope and other instruments are inserted with
the aid of a large trocar through a single umbilical incision. Laparoscopic appendectomy via
a single umbilical incision is a less invasive procedure associated with minimal or no
scarring compared to the traditional laparoscopic operation. Postoperative pain, nausea and
vomiting are common problems encountered with laparoscopic appendectomy and other abdominal
operations. As an established standard practice at Texas Children's Hospital, pain control
in these patients is achieved by intravenous opioids via a patient controlled device along
with ketorolac tromethamine, as well as local anesthetic infiltration (LAI) performed by
surgeon or bilateral rectus sheath blocks as described below.

The umbilical area is innervated by the bilateral 9th, 10th and 11th intercostal nerves,
which run between the internal oblique and transversus abdominis muscle. At the lateral edge
of the rectus muscle, the nerves perforate the rectus sheath and innervate the rectus
muscle. Anterior cutaneous branches cross the muscle supplying the skin of the umbilical
area. Successful blockade of the relevant intercostal nerves within the rectus sheath can
provide effective pain relief for umbilical and other midline surgical incisions. Rectus
sheath block has also been shown to give better pain control when compared with
intra-incisional infiltration and intra-peritoneal injection in patients undergoing
laparoscopic gynecologic surgery. Recently, it has been shown that there is improved
efficacy and a decreased local anesthetic requirement when ultrasound is used to guide
rectus sheath block in children undergoing umbilical hernia repair. However, data comparing
pain after ultrasound guided bilateral rectus sheath block (UGBRSB) and peri-umbilical local
anesthetic infiltration (LAI) for SILA are not available. The incidence of postoperative
nausea and vomiting (PONV) is high after laparoscopic surgery, with a dose-related increase
noted when opioids are used in the postoperative period. Effective regional anesthesia may
decrease opioids use and consequently reduce the incidence of PONV and improve patient
satisfaction.

Inclusion Criteria:

- 1) Acute appendicitis (2) Age 6 - 17 years (3) American Society of Anesthesiologists
Physical Status I - III (4) Patients undergoing SILA procedure performed by a single
pediatric surgeon (Dr. Ashwin P. Pimpalwar) (5) Patients judged by parents,
physicians and other caretakers as being capable of using the patient controlled
analgesia (PCA) device.

Exclusion Criteria:

- 1) Patients who are not scheduled to undergo the procedure of SILA. (2) Patients with
allergies to local anesthetics (3) Patients who do not understand or cannot use the
pain rating scale because of developmental delay, language or other issues. (4)
Patients with concomitant major cardio-respiratory disorders. (5) Patients judged to
be incapable of using the PCA device (6) Patients who refuse to participate in the
study