None listed
Conditions
Brief summary
When performing a laparoscopic appendicectomy the surgeon injects local anaesthetic to numb the sites where “keyhole” ports, used for the surgical instruments, are placed through the abdominal wall. For the first port, placed at the belly button (umbilicus) local anaesthetic is placed under the skin, but much of the pain after the operation may come from the deeper tissue layer at the level of “abs” muscles (rectus abdominis). The rectus sheath nerve block, in which local anaesthetic is injected just behind the rectus muscle to numb the nerves that supply the umbilicus, has been shown to be safe and effective in paediatric umbilical operations. Rectus sheath nerve blocks have not been previously studied in paediatric laparoscopic appendicectomy to our knowledge, although a similar block called the TAP (transversus abdominis plane) has been shown to be effective. The possible advantage of the rectus sheath block is that the anaesthetic is placed closer to the umbilicus, and it is easy to perform. Needle placement during a rectus sheath nerve block is more accurate, and possibly safer, when ultrasound is used to ‘see’ where the needle is going. We propose to investigate how an ultrasound guided rectus sheath nerve block can reduce pain after laparoscopic appendicectomy for acute appendicitis.
Interventions
After induction of anaesthesia an ultrasound-guided rectus sheath ‘nerve-block’ will be performed by the surgeon or anaesthetist.
Nerve block technique:
Guided by an axially orientated ultrasound image incorporating the lateral edge of the rectus muscle the needle will be inserted in-plane to the ultrasound beam and its tip advanced under visualisation to the posterior extent of the rectus muscle. A hypo-echogenic lentiform swelling between posterior rectus sheath and rectus muscle on injection
After induction of anaesthesia an ultrasound-guided rectus sheath ‘nerve-block’ will be performed by the surgeon or anaesthetist. Nerve block technique: Guided by an axially orientated ultrasound image incorporating the lateral edge of the rectus muscle the needle will be inserted in-plane to the ultrasound beam and its tip advanced under visualisation to the posterior extent of the rectus muscle. A hypo-echogenic lentiform swelling between posterior rectus sheath and rectus muscle on injection of a small amount of solution will help confirm correct needle tip position. Half of the solution will be injected at this point. The process will be repeated on the contralateral side. Local anaesthetic dose: The volume of solution available for the nerve block will be calculated according to the patient’s body weight up to a maximum of 20ml, to maintain a maximum dose of bupivacaine at or below 2.5mg/kg. Volume (ml) = Weight (kg) -10 Half the volume will be used for each side. In addition to the nerve block, 10ml 0.25% bupivacaine with 1:400,000 adrenaline will be available for the surgeon for local infiltration of all port sites. The nerve block is performed once intraoperatively and not repeated.
Sponsors
Auckland District Health Board
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Treatment
Masking
Blinded (masking used)
Eligibility
Sex/Gender
All
Age
8 Years to 14 Years
Healthy volunteers
No
Inclusion criteria
All children presenting to Starship Children’s Hospital, aged between 8 and 14 years, diagnosed with acute appendicitis requiring urgent laparoscopic appendectomy.
Exclusion criteria
Diagnosis of developmental delay, neuro-muscular impairment, attention-deficit disorder, chronic pain, or psychiatric illness. Unable to speak and read English Partially sighted or blind Previous open abdominal surgery Presence of any abdominal prostheses such as a gastrostomy or ventriculo-peritoneal shunt Immuno-suppression Allergy to morphine Consent not obtained from both the participating child and one parent or legal guardian
Outcome results
None listed