percutaneous rectus sheath block versus intra-operative rectus sheath block for pediatric umbilical hernia repair

Conditions: Pain, Postoperative

Summary: this is a prospective, double-blinded, randomized controlled study comparing the efficacy of pre-incisional percutaneous rectus sheath block to intra-operative rectus sheath block under direct visualization prior to closure of the incision for providing post-operative analgesia following umbilical hernia repair in children. the current management for reducible umbilical hernias is umbilical hernia repair under general anesthesia as an outpatient procedure. patients aged 3-18 years old with a diagnosis of umbilical hernia will be screened for study inclusion. eligible patients and their parents/guardians will be approached and, if agreeable, consented for the study pre-operatively. patients will be randomized to receive either pre-incisional percutaneous rectus sheath block by the anesthesiologist or intra-operative rectus sheath block under direct visualization prior to closure of the skin incision by the surgeon. the patient, patient guardians, select research team members, and post-anesthesia care unit (pacu) staff will be blinded to the method of analgesic administration.

regional anesthesia has been increasingly utilized for providing post-operative analgesia for a number of surgical procedures in children. rectus sheath block and local anesthetic infiltration of the surgical site are two common modes for providing post-operative analgesia following umbilical hernia repair. studies comparing the two modes have shown ultrasound-guided rectus sheath block to improve immediate pain scores and reduce use of post-operative analgesia in pediatric patients undergoing umbilical hernia repair. however, these studies have compared pre-incisional ultrasound-guided rectus sheath block to post-operative local anesthetic infiltration as a subcutaneous and/or intradermal injection. the purpose of the investigators' study is to compare the efficacy of pre-incisional percutaneous rectus sheath block to intra-operative rectus sheath block under direct visualization prior to closure of the skin for providing post-operative analgesia following umbilical hernia repair in children. the investigators propose a prospective study where pediatric patients who are undergoing elective umbilical hernia repair will be randomized pre-operatively to receive either pre-incisional, ultrasound guided percutaneous rectus sheath block or intra-operative rectus sheath block under direct visualization prior to closure of the skin. the primary outcome is the post-operative pain rating based on the wong-baker faces pain rating scale (wbfprs) following umbilical hernia repair. additional outcomes measured will include: operative times, the use of intravenous/oral opioid and/or non-opioid medication in the post-operative period, duration of analgesia following surgery based on time to first rescue analgesic, intra-operative hemodynamic changes, post-operative hemodynamic changes, incidence of side-effects, and complications. patients/patient guardians will receive a sheet to document post-operative wbfprs scores, oral opioid and non-opioid medication administration once discharged to home for a total of 5 days.

Eligibility criteria:
inclusion criteria: * patients aged 3-18 years undergoing elective umbilical hernia repair exclusion criteria: * strangulated or incarcerated umbilical hernia (non-elective) * allergy to bupivacaine/ropivicaine * concurrent surgical procedures * developmental delay or neurologic diagnosis that would interfere with post-operative pain score assessment * chronic pain medication use * chronic pain disorder or complex regional pain syndrome * anesthesiologist classification of iii or greater.