A Comparison of UGBRS Block and Local Infiltration
Condition: Appendicitis
MeSH terms: Appendicitis
Study type: Interventional
Phase: Phase 4

Summary: 
      In this research study, the investigators are trying to find out which of the two methods of
      injecting local anesthetics (at the site of the belly button cut or by ultrasound guided
      rectus sheath block) will provide better pain relief and less need for pain medication after
      surgery in children undergoing single incision laparoscopic appendectomy.
    

Detailed description: 
      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.
    

Intervention name(s): UGBRSB; Local Infiltration
Intervention type(s): Procedure; Procedure
Intervention description(s): Under sterile conditions,the posterior rectus sheath will be identified by ultrasound, and an insulated 22 gauge 50 mm needle inserted till the tip is seen to be directly between the rectus abdominis muscle and the posterior rectus sheath. Bupivacaine 0.25% (0.2 ml/kg with maximum 5 ml in each side) will be injected observing the spread on the ultrasound image.; In those patients randomized to the LAI group, the surgeon will perform infiltration of 0.5 ml/kg of 0.25% bupivacaine (maximum, 10 ml) around the incision
Other intervention name(s): Ultrasound Guided Bilateral Rectus Sheath Block; Local Anesthetic Infiltration
Intervention MeSH terms: Anesthetics; Anesthetics, Local
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Treatment