A novel anaesthetic technique for laparoscopic inguinal hernia repair in infants and neonates

Presented During:

Sunday, May 19, 2019: 12:30 PM  - 2:00 PM 
The Fairmont Queen Elizabeth  
Room: Place du Canada / Square Dorchester  

Session Number:

1278 

Session Type:

Abstract Submissions 

Introduction:

Inguinal hernia repair (IHR) is one of the most commonly performed surgical procedures in infants (1). Recently, the laparoscopic approach to IHR in small children has gained in popularity, with purported advantages including the diagnoses and repair of the contralateral patent processus vaginalis (PPV) (2,3). While the traditional, "open" approach is typically performed under general anaesthesia (GA) with an endotracheal tube and a caudal block, the use of a caudal or spinal block with minimal sedation has been promising (4,5). Avoiding a GA could potentially avoid anaesthetic-related neurotoxicity (6), complications of tracheal intubation (7) and possibly reduce the risk of postoperative apnoeas in high-risk patients (8). This anesthetic technique has not been described for the laparoscopic approach.
In this paper, we present a retrospective chart review describing the novel technique and quantifying relevant outcomes of caudal blockade, combined with intravenous (IV) sedation and spontaneous respiration with supplemental oxygen via nasal prongs (NP) for laparoscopic IHR in infants.

Methods:

We undertook a retrospective chart review of all laparoscopic inguinal hernia repairs performed on infants at our institute between July 1st 2016 and October 31st 2018. Patients were excluded when the hernia repair occurred in conjunction with other major surgical procedures. We collected data related to demographics, anaesthetic and surgical techniques and perioperative incidence of apnoeas and desaturation.
The anaesthetic technique
Informed consent for the technique was obtained preoperatively. In the operating room (OR), an IV cannula was sited and 1- 1.5mcg/kg of dexmedetomidine was administered intravenously over 3 - 5 minutes. Oxygen (1-2 L/m) was delivered via NP with capnography. Boluses of propofol were given as required, to allow a caudal epidural injection. Loss of tone in the legs and lack of response to a sterile abdominal prep solution were indicative of motor and sensory blockade. In vigorous infants, an infusion of propofol (1%) with remifentanil (2.5 mcg/ml) was initiated at a rate of 30 to 150 mcg/kg/min of propofol.
Analysis
"Success" as defined by completion of laparoscopic surgical repair with the described technique, was the primary outcome.
The secondary outcomes were the incidence of desaturation and apnoeas up to 24 hours postoperatively, and OR utilization as measured by time spent at various stages of the patient's procedure. Data was tabulated and analyzed using descriptive statistics.

Results:

Eleven patients were eligible, of whom 10 were born preterm (Table 1). Mean post-menstrual age was 42.8 weeks and mean weight was 4.06 kg.
The technique was successful in all 11 cases and involved the same surgeon. The mean anaesthesia preparation time was 21.6 min (Table 2). Mean procedure time was 36.1 min, with operative pneumoperitoneum pressures deliberately reduced to 8-12 mmHg. All patients received IV dexmedetomidine, 5 received a propofol infusion only, 3 received an infusion and boluses and 3 received boluses only (Table 3).
2 patients scheduled for unilateral hernia repair had bilateral repair (Table 4).
In PACU, there were 2 cases of transient desaturation, which recovered with tactile stimulation. One patient received IV morphine for analgesia.
Nine patients went to a high dependency unit for overnight apnoea monitoring as planned and were discharged the following day. Two returned to the intensive care unit, their original location. There were no documented incidents of apnoeas and desaturation overnight.

Conclusion:

A similar technique has been previously described for open inguinal hernia repairs (4,5), but there are no reports of using this technique for a laparoscopic approach. We believe that the advantage of avoiding airway instrumentation under a general anaesthetic, while still allowing a laparoscopic approach, makes this a better anaesthetic technique for the management of inguinal hernias in infants.
OR utilization seemed acceptable but will need to be the topic of a future study. There were no major complications intraoperatively or postoperatively. The technique was successful in all cases.
In conclusion, although the numbers are small, this case series demonstrates the feasibility of using a caudal epidural anaesthetic with IV dexmedetomidine and propofol (with or without remifentanil) for laparoscopic inguinal hernia repair in infants and neonates without airway instrumentation.

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Pediatric Anesthesiology

Tables_PKrishnan.docx
 

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