Percutaneous Rectus Sheath Block Versus Intra-operative Rectus Sheath Block for Pediatric Umbilical Hernia Repair
Condition: Pain, Postoperative
MeSH terms: Hernia, Umbilical; Pain, Postoperative
Study type: Interventional

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.
    

Detailed description: 
      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.
    

Intervention name(s): Pre-op percutaneous rectus sheath block; Intra-operative rectus sheath block; Ropivacaine
Intervention type(s): Procedure; Procedure; Drug
Intervention description(s): After induction of anesthesia, the attending anesthesiologist will use a portable ultrasound probe to locate the rectus sheath. A 22 gauge needle will be used to inject a predetermined volume of 0.2% ropivacaine (1cc/kg, max dose 10cc, divided into equal doses bilaterally). The analgesic will be injected percutaneously using ultrasound guidance between the rectus abdominis muscle and the posterior rectus sheath at the lateral border bilaterally.; After the completion of the umbilical hernia repair, after fascial closure, but prior to skin closure, a predetermined volume of 0.2% ropivacaine (1cc/kg, max dose 10c, divided into equal doses bilaterally) will be administered under direct visualization into the rectus sheath bilaterally by the attending surgeon.
Other intervention name(s): Naropin
Intervention MeSH terms: Ropivacaine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Supportive Care