A Comparison of UGBRS Block and Local Infiltration
A Comparison of UGBRS Block and Local Infiltration
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.
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