Evaluating Pain Outcomes of Caudal vs Ilioinguinal Nerve Block in Children Undergoing Orchiopexy Repair
Evaluating Pain Outcomes of Caudal vs Ilioinguinal Nerve Block in Children Undergoing Orchiopexy Repair
Surgical intervention to treat undescended testis is a very common pediatric surgical
 procedure, often performed using an inguinal incision or subscrotal incision approach.
 Children who undergo orchiopexy can suffer from a significant degree of discomfort
 postoperatively. The investigators are evaluating the effectiveness of an ultrasound guided
 caudal-epidural (CE) block to an US guided ilioinguinal/iliohypogastric (IIG/IHG) nerve block
 in achieving post operative analgesia following a orchiopexy repair. It is hypothesized that
 US guided IIG/IHG nerve block leads to more effective pain control post-operatively while in
 hospital relative to an US guided CE block for orchiopexy surgery.
Surgical intervention to treat undescended testis is a very common pediatric surgical
 procedure, often performed using an inguinal incision or subscrotal incision approach.
 Children who undergo orchiopexy can suffer from a significant degree of discomfort
 postoperatively. A multimodal pain management approach including medications such as
 acetaminophen, non-steroidal anti-inflammatory drugs and opioids have traditionally been used
 in combination with a regional anesthetic technique. Regional anesthetic techniques include
 surgical infiltration of local anesthetic, caudal-epidural (CE) block or an
 ilioinguinal/iliohypogastric (IIG/IHG) nerve block.

 Regional anesthetic techniques such as CE and ultrasound (US) guided IIG/IHG are
 well-established methods shown to reduce the use of intraoperative anesthetics and the need
 post operative rescue analgesia. Traditionally, IIG/IHG nerve blocks were completed using a
 landmark-based approach but due to unpredictable block results with failure rates over 30%
 and potentially serious complications such as unintentional intraperitoneal injection, many
 anesthesiologists preferred the more reliable CE technique (2, 3). However, while the CE
 provides excellent intraoperative anesthesia it provides short duration of post-operative
 analgesia (4-6 hours) and can be associated with lower limb motor block and urinary retention
 (4). Recent literature has demonstrated that an US guided IIG/IHG can be completed with
 smaller volume of local anesthetic with a success rate of up to 100% with low risk of
 complications. Furthermore there is evidence to suggest that it provides an increased
 duration of postoperative analgesia for pediatric patients undergoing groin surgery (3, 5).
 Finally, two publications retrospectively reviewing complications in over 45000 regional
 anesthetic blocks suggest that US guided peripheral nerve blocks (e.g., IIG/IHG) should be
 favoured over neuraxial techniques such as epidural and caudal anesthetics due to the
 risk-benefit profile (6,7). A recent meta-analysis comparing IIG/IIH block to the CE block in
 children notes that additional comparative studies are required as previous studies comparing
 these two techniques have many methodological limitations including small sample sizes, using
 blind (non-US guided) regional anesthetic techniques and grouping patients undergoing various
 surgical procedures (e.g., orchiopexy and hernia repair) despite significant differences in
 recovery pain profiles (8).

 The investigators are proposing to complete a prospective randomized single-blinded
 non-inferiority study to evaluate and compare the effectiveness of an US guided CE block to
 an US guided IIG/IHG nerve block in achieving post operative analgesia following orchiopexy
 for undescended testicle(s). Currently, a number of Pediatric Anesthesiologists at the
 Alberta Children's Hospital do not routinely complete IIG/IIH or CE blocks under ultrasound
 guidance. As part of this study investigators hope to provide necessary knowledge
 (sonoanatomy, technique) and offer supervised clinical training to anesthesiologists who are
 interested in participating in the study. While orchiopexy remains a common procedure, no
 studies have compared the use of US guided CE to US guided IIG/IHG. The aim of this study is
 to establish non-inferiority in post-operative pain while in hospital as assessed through the
 Face, Leg, Activity, Cry, Consolability (FLACC) scale for the US guided IIG/IHG as compared
 to US guided CE following orchiopexy surgery. Secondary objectives will assess for group
 differences in need for rescue analgesia in hospital, analgesia administered at home, and
 postoperative pain measures within 24 hours post hospital discharge.

 The investigators hypothesize that a US guided IIG/IHG nerve block leads to non-inferior
 objectively measured FLACC pain scores (≤ 1 point on FLACC scale) post-operatively while in
 hospital relative to an US guided CE block for orchiopexy surgery.
Inclusion Criteria:

 -  Healthy children (ASA I and II) between the ages of 6 months and 4 years presenting
 for elective orchiopexy repair who are scheduled for day stay only.

 Exclusion Criteria:

 -  Patients with a history of clinically important renal, hepatic, cardiac, or
 neurological conditions and those with a history of allergic reactions to local
 anesthetics, bleeding diatheses, coagulopathy, and spinal abnormality such as a sacral
 dimple will be excluded.