I

II

III

IV

ACKNOWLEDGEMENT It is most appropriate that I begin expressing my indebtedness gratitude to my beloved parents and family members for being supportive in all my endeavors. It gives me great pleasure in preparing this dissertation and I take this opportunity to thank everyone who have made this possible. First and foremost I would like to express my deep gratitude and sincere thanks to my guide Dr. M.J. MAHANTHESHA SHARMAM.D.,D.A. Professor, Department of Anaesthesiology, J.J.M Medical College, Davangere for preparing me for this task, guiding me with his superb talent and professional expertise, showing great care and attention to details and without his supervision and guidance this dissertation would have been impossible. I am highly indebted to Dr. D. MALLIKARJUNA
M.D., D.A.,

Professor and

Head, Department of Anaesthesiology, J.J. M. Medical College, Davangere, for his constant efforts in fine tuning my practical skills and inculcating in me the importance of hard work, dedication and commitment during my course. I will remain grateful to him for the constant guidance and inspiration he has given to me. It gives me immense pleasure to extent my sincere thanks to Professors Dr. MANJUNATHA JAJOOR PALAKSHAPPA
M.D,D.A M.D., D.A..,

Dr. R. RAVI

M.D.,D.A.,

and Dr. K.R.

whose authoritative knowledge of practical skills has

guided and inculcated in me a sense of confidence. I am thankful to them for their valuable teaching and guidance. I am extremely thankful to associate professors Dr. NALINAKSHAMMA SAJJAN M.D., D.A., Dr. R. ASHOK M.D., and Dr. RAJANNA SAHUKAR, M.D.,D.A., for their constant guidance throughout the course. I would like to thank Readers, Dr. M.N. CHIDANANDASWAMY Dr. R.B. RAVISHANKAR
M.D.,D.A., M.D., M.D.,

Dr. B.M. CHANDRAKUMAR A.R.

VI

Dr. D.B. PRAKASH

M.D.,

Dr. C. RAVIKUMAR

M.D.,

Dr. RAMAPPA

M.D.,D.A.,

Dr. B.G. PRABHU M.D., for their valuable guidance. My heartful thanks to Assistant Professors Dr. G.S. PRASANNA Dr. ANITHA HANJI encouragement. I owe a great sense of indebtedness to Dr. GURUPADAPPAM.D., Director, Post graduate studies and research and Dr. H.R. CHANDRASEKHAR Principal for allowing me to use the institutional facilities. I express my sincere thanks to CHIEF LIBRARIAN and informative Centre members for their valuable support. I would also like to thank superintendent and OT staff of Chigateri General Hospital and Bapuji Hospital, for their co-operation and assistance. My sincere thanks to Mrs. RAJASHRI PATIL, statistician who guided statistical analysis. I express my sincere thanks to post graduate colleagues and all my friends, who have helped me in preparing this dissertation. I ever pray Almighty for all his blessings. My special thanks to M/s ZEN COMPUTER TECHNOLOGY for their meticulous typing and styling of this script. Last but not the least I express my special thanks to all my patients, who in the final conclusion are the best teachers and without whom this study would have been impossible.
M.D., M.D., M.D.,

and Dr. B.R. UMA

M.D.,

for their advice and constant

Date :

/ 2007 Dr. SHIVAKUMAR

Place : DAVANGERE K.P.

VII

LIST OF ABBREVIATIONS USED

+epi ASIS ASISP ASU ECG Gx HCL IFA IHNB LD LI LMA MAP MEGX MIN MPI With epinephrine Anterior superior iliac spine Anterior superior iliac spine point Ambulatory surgery unit Electrocardiograph Glycide xylidide Hydrochloric acid Inguinal field block Ilio inguinal ilio hypogastric nerve block Left direct inguinal hernia Left indirect inguinal hernia Laryngeal mask airway Mean arterial pressure Monoethylglycine xylidide Minutes Mid point of the inguinal ligament Nerve block under monitored anaesthesia care Post anaesthesia care unit Post anaesthetic ward Post operative nausea vomiting Right direct inguinal hernia Right indirect inguinal hernia Sub arachnoid block Subcutaneous Visual analogue scale

NB (MAC) PACU PAW PONV RD RI SAB SC VAS -

VIII

ABSTRACT
Background and objectives : Present clinical study was conducted to evaluate advantages of field block for inguinal hernia repair, with respect to duration and quality of analgesia, haemodynamic stability, and speed of recovery by using 1% lidocaine with adrenaline. Methods : Study was conducted on 50 patients posted for elective inguinal hernia repair. Field block was instituted with 1% lidocaine with adrenaline with mean volume of 35.48 ml to block ilioinguinal, iliohypogastric, genital branch of genitofemoral nerve with subcutaneous infiltration. Patients were observed for duration and quality of analgesia. Haemodynamic stability with PR, systolic and diastolic BP. Post anaesthesia recovery was assessed by using criteria for fast track eligibility for ambulatory anaesthesia after the surgery. Duration of analgesia was assessed with subjective complaint of pain (duration of onset of analgesia till the subjective complaint of pain). Results : In the present study, the quality of analgesia was excellent in 72% of cases, good in 16%, fair in 8% and poor in 4%. The mean duration of analgesia was 201.02 min (160 min to 280 min). All patients were haemodynamically stable throughout the surgery. Using fast tract eligibility criteria for recovery all the patient had a score of 12 at 0 min and all of them had score of > 12 at 15 min and 30 min and were ready to be shifted to ward from the OR bypassing the post anaesthesia recovery room. Conclusion : Thus field block for inguinal hernia repair is a safe technique, that provides excellent quality and prolonged analgesia, with rapid recovery and minimal to nil complications. Keywords : Inguinal field block; excellent analgesia; haemodynamical stability; rapid recovery.

IX

TABLE OF CONTENTS

Page No. 1. Introduction 1

2.

Objective

3.

Review of literature

3-30

4.

Methodology

31-43

5.

Results

44-58

6.

Discussion

59-68

7.

Conclusion

69

8.

Summary

70-72

9.

Bibliography

73-77

10. Annexures Proforma Consent form Master chart 78-80 81 82-86

LIST OF TABLES Sl. No. 1 2 3 Tables Local anaesthetic properties and characteristics Recovery scale after outpatient herniorrhapy Criteria used to determine fast-track eligibility after ambulatory anaestheisa 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Age distribution Sex distribution Weight distribution Type of hernia Volume of lignocaine 1% with adrenaline used Quality of analgesia and relaxation Duration of surgery Duration of analgesia Mean heart rate changes Mean blood pressure changes SpO2 changes Intraoperative complications Analgesia and relaxation (success rate) Recovery scale - Parameter 1 : Physical activity Recovery scale - Parameter 2 : Respiratory stability Recovery scale - Parameter 3 : Haemodynamic stability Recovery scale - Parameter 4 : Level of consciousness Recovery scale - Parameter 5 : Oxygen saturation status 44 45 45 46 47 48 49 50 51 52 53 54 54 55 55 55 56 56 Page No. 8 14 38

XI

22 23 24 25

Recovery scale - Parameter 6 : Post operative pain assessment Recovery scale - Parameter 7 : Post operative emetic symptoms Recovery scale - Parameter 8 : Total score Number of patients achieve fast track eligibility score of 12 and above

56 57 57 57

26 27 28

Volume of lidocaine with adrenaline used in three studies Duration of surgery Various studies for hernia repair under field block or monitored anaesthesia

61 63 65

29

Fast-track eligibility mean score

72

XII

LIST OF GRAPHS Sl. No. 1 2 3 4 5 6 7 8 9 10 11 12 Age Distribution Weight Distribution Type of Hernia Volume of Lidocaine 1% with Adrenaline Used Quality of Analgesia and Relaxation Duration of Surgery Duration of Analgesia Mean Heart Rate Changes Mean Blood Pressure Changes SpO2 Changes Analgesia and Relaxation (Success Rate) Fast Track Eligibility Score of 12 and Above Graphs Pg. No. 44 45 46 47 48 49 50 51 52 53 54 58

XIII

LIST OF FIGURES Sl. No. 1 2 3 Figures Inguinal field block anatomy Inguinal block anatomy and technique Inguinal block cross sectional anatomy and technique Pg. No. 19 35 35

Sl. No. 1 2 3

Photographs Materials used for field block for inguinal hernia repair Reducible indirect inguinal hernia Administration of local anaesthetic agent to a point half an inch medial to ASIS along spino-umbilical line

Pg. No. 40 40 41

Administration of local anaesthetic agent to a point medial to pubic tubercle

41

Administration of local anaesthetic agent to a point 0.5cm above the mid point of the inguinal ligament

42

Subcutaneous infiltration of local anaesthestic agent along the line of incision

42

Subcutaneous infiltration of local anaesthestic agent along spino-umbilical line

43

Subcutaneous infiltration of local anaesthestic agent from pubic tubercle to umbilicus

43

XIV

Introduction

INTRODUCTION
Hernia is the word derived from Greek words Herons an offshoot or bulge. It is defined by Sir Astley Cooper (1804) as protrusion of any viscus or part of the viscus through an abnormal opening in the walls of its cantaining cavity.1 Inguinal hernia repair is one of the common treatment performed. With appropriate techniques the block provides excellent surgical and post operative analgesia for hernia repair, simplifying anaesthetic surveillance and postoperative care. The performed choice of anaesthesia for all adult inguinal hernia repair is local, it is safe, simple, effective, and economical, with out post anaesthetic side effects. Further more local anaesthesia administered before the incision produces longer postoperative analgesia because local infiltration, theoretically inhibits build of local nociceptive molecules and therefore, there is better pain control in the postoperative period.2 Hernia repair can be performed under spinal, epidural, general and inguinal field block. Field block for inguinal hernia repair is the most cost-effective anaesthetic technique for out patients undergoing unilateral inguinal herniorrhaphy with respect to speed of recovery, patient comfort and associated incremental costs.3 These are not provided into a satisfactory level by the commonly employed techniques, such as general anaesthesia or centrineuraxial blockade. Hence to meet the above requirements the present study of field block for inguinal hernia repair is undertaken.

Objectives

OBJECTIVES
This study is undertaken to evaluate the advantages of this field block for inguinal hernia repair. To study the duration and quality of analgesia by using 1% lidocaine with adrenaline. Haemodynamic effects To study the effects of inguinal field block with respect to speed of recovery and patients comfort. Other side effects pertaining to the inguinal field block.

Review of literature

REVIEW OF LITERATURE
Historical review : The out patient, local anaesthesia approach is hardly a new idea. Harvey Cushing described hernial repair under local cocaine anaesthesia in 1900.4 Ernesl Trice in 1947 described the repair of groin hernias under local anaesthesia with ambulation of the patient from the operating room table back to his bed.5 During World War II with the shortage of hospital beds, Trice sent many hernial repair patients back home the day of repair, or to a local motel for three days if the patient was from out of town.4 Since World War II, the shouldice clinic has performed more than 10.000 hernial repairs under local anaesthesa with immediate ambulation.6 Flanagan L and Bascom JU. Repaired 170 hernias in 1969 to 1977 as out patient basis using local anaesthesia. Patient with a significant unstable, systemic illness, would choose to do the repair under local anaesthesia but hospitalize the patient for close post operative monitoring. They now performed over 90% of all groin hernia using local anaesthesia.4 In a review of both the anaesthesiological and surgical literature, one thing stands out : there is no one way to do a field block for hermiorrhphy. The technique in the present has been used with much success over the past 15 years and is one that they believe to be safe, effective, and easy to perform.

With the patient in supine position, a skin wheal is made 1 finger breadth medial to the ASI spine. A 22-Gauge, 1 inch needle is affixed to a syringe containing 10 ml, of 1% lidocaine. Needle is directed perpendicularly to the skin through the skin wheal. As the needle advances two gives will be felt as it passes through the external and internal oblique muscles. The needle should now lie just superior to the fascia transversalis, through which the ilioinguinal nerve arises. The 10 ml, is now injected in fanwise fashion, that is, cephalad, caudad, and laterally, but never medially. The infiltrations now made superficially in an attempt to block the iliohypogastric at this point; it is preferable to concentrate on obtaining a solid ilioinguinal block, since this is the foundation of the technique. A second skin wheal is now raised over the pubic tubercle on the side to be blocked. The same 22 gauge, 1 inch needle affixed to a syringe containing 10 ml of 1% lidocaine is directed perpendicularly through this wheal until the pubic tubercle is contacted. The needle is then walked off the patient in cephalad direction until the cartilagenous structure known as coopers ligament is contacted. The 10 ml 1% lidocaine is now injected into and along this cartilaginous structure, with care to avoid midline again, since the bladder may get, in the way in that direction. The remainder block is done with a 22 gauge, 3 inch (9 cm) block needle and 0.5% lidocaine, with subcutaneous infiltration only. Starting at the skin wheal medial to the anterior SI spine, a subcutaneous furrow run obliquely to the umbilicus.

This will block any overlapping fibers from the inter costal nerves above, subcutaneous furrows are now raised from this same skin wheal in three directions : 1) From the skin wheal to a point midway between the umbilicus and pubis. 2) From the skin wheal laterally over the ilium onto the anterolateral portion of the hip. This furrow should make a right angle with the first of these furrows and be of a similar length. 3) From the skin wheal, bisecting the right side angle, paralleling Pouparts ligament, and reaching halfway to the skin wheal over the pubic tubercle. The block needle is now moved to the skin wheal over the pubic tubercle and the tripod appearance of the other three furrows is now completed to make a large diamond. 1) The medial projection of this diamond blocks any innervation that might cross over the midline. 2) The lateral projection blocks an area covered by the lateral femoral cutaneous nerve and permits a transverse hernia incision by the surgeon. 3) The center of the diamond that parallels Pouparts ligament strengthens the usual line of incision, allowing for almost immediate incision. Using the same skin wheal over the pubic tubercle, a subcutaneous furrow in the shape of an inverted V is described. The first limb of this inverted V runs from the skin wheal down to the beginning of the scrotal skin. The lateral limb of the inverted V runs obliquely over the inguinofemoral fold and onto the thigh. This inverted V will block any recurrent branches from the femoral nerve and will obviate the need for a separate femoral nerve block.

When the hernia is reducible, the middle finger of the opposite hand is invaginated through the scrotum and up into the external inguinal ring. Directing the block needle again through the skin wheal overlying the pubic tubercle, the external inguinal ring can be infiltrated, the needle is easily directed by the invaginated finger, and by keeping this finger between the cord and the needle, the external ring can safely be blocked without fear of hematoma or puncture of the hernia sac. This leaves only the internal ring for the surgeon to block. Unless he does this block, the patient will be subject to traction pain and reflexes. To obviate some of the consequences of these traction reflexes, we always give atropine in our premedication. The remainder of our premedication is purposely kept light, using Diazepam, 10 mg, Secobarbital, 75 to 100 mg, or Fentanyl, 0.05 to 0.1 mg intramuscularly. We also expect to get some sedation from the Lidocaine we have used. If more sedation is needed, we can always add it; subtracting it is much more difficult. The total amount of lidocaine used will vary from 375 to 500 mg. : 20 ml. of 1 percent lidocaine (200 mg). and 35 to 60 ml. of 0.5 percent lidocaine. We do not use epinephrine because most of our patients are in the older age group, and we prefer that they receive no exogenous epinephrine. The block, without epinephrine, will last from 60 to 75 minutes.7 A series of 117 consecutive unselected patients with clinically reducible unilateral inguinal hernia were admitted for short stay repair. Seven expressed a strong preference for one form of anaesthesia [6 general (GA) 1 local (LA)] and 7 were unfit for GA; they were excluded from trial.

The remaining 103 patients were allocated at random to receive either LA or GA in order to compare the two methods of anaesthesia. Peri and postoperative symptoms were assessed with linear analogue self assessment questionnaires. Statistically significant differences were demonstrated between the groups and they concluded that LA was applicable to all types of clinically reducible inguinal hernia and was an acceptable, safe, and satisfactory alternative to General Anaesthesia.8 An extensive review of one-lakh patients undergoing herniorrhaphy with a mean age of 58 years adds stressed importance of local anaesthesia as it would be used in poor risk patients and also it avoids general anaesthesia risk.9 A study was made on 400 consecutive patients who underwent inguinal herniorrhaphy between 1979 and 1982, to determine whether the choice of anaesthetic technique in elective inguinal herniorrhaphy affects patients satisfaction and post operative complications. At the end of study, they concluded that satisfaction rating were equal in local, general or spinal anaesthesia however local anaesthesia had the lowest complication rate in those over 65 and those with concomitant illness.10 A study was conducted to compare ilio-inguinal nerve block and wound infilteration for post operative analgesia with 49 boys scheduled for day case inguinal herniotomy. They concluded that both techniques provide satisfactory analgesia whilst the complications of narcotics are avoided, and suggest that simple infiltration of the wound with local anaesthetic solution should be encouraged in paediatric anaesthesia.11

In another study with thirty male children aged 3 months to 13 years scheduled for bilateral inguinal herniorrhaphy under GA, percutaneous inguinal block was performed with 0.25% bupivacaine for out patient management of postherniorrhaphy pain in children. They concluded that the technique is easy to perform, requires very little extra time, and has very few side effects. Inguinal nerve block are effective especially for pediatric post operative pain control.12 A randomized, double-blind study was conducted on 32 patients undergoing herniorrhaphy with three types of anaesthesia. Group I with general anaesthesia, group II general anaesthesia + local anaesthesia and group III with SAB. For local anaesthesia 0.25% bupivacaine was used. The severity of constant incision pain, movement associated pain, and pain on application of pressure was assessed with algometer using VAS self-rating method at intervals of 24 hour, 48 hour and 10 days. They concluded that, where local anaesthesia was used the pain was very less compared to general anaesthesia or SAB. From this they drew a hypothesis that neural blockade suppresses the formation of the sustained hyperexcitable state in the CNS that is responsible for the maintenance of post-operative pains by preventing noceceptive impulses from entering CNS during and immediately after surgery.13 TABLE 1 : LOCAL ANAESTHETIC PROPERTIES AND CHARACTERISTICS14 Lidocaine Trade name pKa % Nonionized Lipid solubility Protein binding Xylocaine 7.9 25 2.9 64%

Infiltration Concentration Maximum dosage 0.5% - 1.0% 5mg/kg (Plain) 7mg/kg (+epi) Onset (min) Duration (min) <1 75-120

Nerve block Concentration Maximum dosage Onset (min) Duration (h) 1.0% - 2.0% As above 1-5 1-3

Spinal Concentration Dosage (mg) Onset (min) Duration (h) 5% 50-100 2-5 0.5-1.5

Epidural Concentration Dosage (mg) Onset (min) Duration (h) 2% 200-400 5-10 0.75-2.0

An inguinal field block was carried out using 0.5-1% lidocaine. From a point one centimeter medial to anterior superior iliac spine, a needle was inserted perpendicular to the skin until contact with bone was established. 5 ml of 1% lidocaine with epinephrine was injected during retraction of the needle to the skin level. From the same point of injection 0.5% lidocaine 20ml with epinephrine was injected under the aponeurosis of the external oblique muscle, 0.5% lidocaine 20 ml with epinephrine was injected subcutaneously both in a fan wise fashion, in the medio

caudal direction covering the surgical field 1% lidocaine 5 ml with epinephrine was then injected directing at the pubic tubercle and finally 1% lidocaine 5 ml with epinephrine was injected into the inguinal canal form a point between the anterior superior iliac spine and pubic tubercle. Total dose of lidocaine used was 350 mg with epinephrine.15 A retrospective study involving 12,000 patients posted for herniorrhaphy under local anaesthesia with 50:50 mixture of 1% lidocaine and 0.5% bupivacaine, concluded that the choice of anaesthesia for uncomplicated hernia repair is local anaesthesia, because local infiltration is safe, simple, effective, cost effective technique without post-anaesthesia complications. They further said that preincisional infiltration has better post-operative pain relief.2 A double blind study was conducted to know the effect of an ilioinguinal hypogastric nerve block with bupivacaine 0.25% on the post-operative analgesic requirements and requiring profiles in the patients undergoing herniorrhaphy on out patient basis on 30 patients. 30 ml of bupivacaine or saline was used for ilioinguinal hypogastric nerve block. The surgical site infiltrated with 1% lignocaine in the PAW (post-anaesthetic ward). By using VAS the pain score was recorded. Fit for discharge was 112 minutes for bupivacaine group compared to 126 minutes saline group. The mean time for ambulation was 86 minutes in bupivacaine group whereas 99 minutes in saline group and analgesic requirement was very less in bupivacaine group.16 In a study using mixture of 0.5% lidocaine HCl + 0.5% bupivacaine HCl for tension-free mesh hernia repair under ilioinguinal nerve block and local infiltration involving 1098 cases in a day unit, they concluded that the tension-free mesh repair

10

under local anaesthesia are simple, with substantial cost savings and very low rates of complications.17 A study was conducted in 76 unselected patients after 79 consecutive operations to asses the feasibility of repair of inguinal hernia under local anaesthesia in an out patient set up. The mean age of the patients was 63 years stayed in hospital overnight after operation. On the first post operative day 27 patients had severe pain during cough and straining. 82% were satisfied with analgesic therapy and were satisfied with ambulatory surgery with local anaesthesia. It was concluded that ambulatory repair of a recurrent inguinal hernia is safe and economical.18,.19 In another study, an analgesic technique such as inguinal field block was performed in four placebo controlled studies supplementary to general anaesthesia pain scores reduced for the first 30 min to 6 hours and reduced the use of analgesics.18,19 A study conducted on 400 consecutive elective herniorrhaphy with local anaesthesia to asses feasibility, safety and cost of infiltration. The mean post operative stay was 85 minutes, 0.5% of cases conversion to general anaesthesia was done. They concluded that the local anaesthesia reduces postoperative pain, reduces cost, and it blocks surgical stress effectively, decrease in morbidity also in an ambulatory setup.18,19 According to Marshall, the recovery is defined as patients returning to preoperative physiological state after surgery. The recovery is divided into three phases. Phase I : Discontinuation of anaesthesia to recovery of protective reflexes and motor function.

11

Phase II : Time till patients have recovered enough to allow their safe transfer to an ambulatory surgical unit recovery. Here Aldrete score is used wherein a score of 9 indicates recovery sufficient to transfer patient from PACU (Post Anaesthesia Care Unit) to ASU (Ambulatory Surgical Unit). Phase III : Full recovery at home. Fast tracking : Where recovery is completed in patients who are transferred from operating room to ASU by passing the PACU the main advantage being cost effectiveness.20 The ilioinguinal and iliohypogastric nerve block is an excellent first maneuver for the surgeon or anaesthesiologist, who performs infiltration anaesthesia, to inguinal hemiorrhaphy.21 In their randomly assigned 81 consenting out patients to receive inguinal hernia nerve block, evaluated the recovery time, 24 hours postoperative side effects, concluded that inguinal hernia NB-(MAC) is the most effective anaesthetic for patients undergoing herniorrhaphy with respect to speed of recovery and patient comfort.3 A study was conducted to assess the safe and effectiveness of anterior tension free repair of recurrent inguinal hernia under local anaesthesia. In their study they included 146 patients of 68 years mean age, mean post-surgical hospital stay of 1.5 days [range 3 hours to 14 days] with no mortality. They concluded that LA seems to be a low cost surgical technique that can be safely and effectively used even in teaching hospital for the treatment of the majority of patients with recurrent groin hernias.22

12

A study was conducted on 25 patients out of 175 patients posted for various ambulatory surgeries, concluded that Blockade of ilioinguinal iliohypogastric nerves can significantly decrease the anaesthetic and analgesic requirements in both children and adults undergoing inguinal hernia repair and provided 6-8 hour postoperative analgesia.23 A randomized study was conducted on 60 patients scheduled for inguinal hernia repair under GA with wound infiltration postoperatively, or inguinal field block (IFB) before surgery, with no or only light sedation intraoperatively. GA was induced with Midazolam, Fentanyl, and Propofol, maintained with Propofol and Alfentanil and supplemented with N2O in oxygen through a LMA. IFB was performed with 50-60 ml of Ropivacaine, concluded that pre-operative inguinal field block for hernia repair provides benefits for patients in terms of faster recovery, less pain, better mobilization and higher satisfaction throughout the whole first postoperative week.24 Dillon commented that regional anaesthesia was provided for any patient having a surgical procedure if it was indicated. It has been demonstrated that the most significant variable that determines the time that is required to discharge a patient from the PACU is the anaesthetic technique. Patients receiving local, monitored anaesthesia care (MAC), and the peripheral nerve blocks all have a decreased incidence of PONV and get discharged earlier. The use of MAC and regional anaesthesia also contributes to lower facility cost and should be aggressively implemented in any facility that is attempting to maximize patient satisfaction and financial performance.25

13

A study stated that Vasomotor effects of lidocaine often resulted in diverse changes in local blood flow. Little reduction of blood flow occurs when 0.5% lidocaine is used, but becomes apparent when 1 to 2% lidocaine used. Addition of epinephrine to lidocaine reduces local anaesthetic plasma concentration and thus minimizes the possibility of systemic toxicity. It also improves the quality and the duration of block.26 A study was conducted on divided 60 patients posted for out patient herniorrhaphy into two groups. There was no difference in age, ASA physical status, weight, height, gender or duration of surgery and anaesthesia, both groups were given propofol and local field block, the study group was treated with Rofecoxib 50 mg, 3040 minutes prior to entry into the operating room, the results of recovery profile as follows. TABLE 2 : RECOVERY SCALE AFTER OUTPATIENT HERNIORRHAPY Control (mins) Mean SD Eye opening Responding to oral commands Orientation Sitting up Tolerate to oral fluids Standing up Ambulating Home readiness Actual discharge Quality of recovery assessment 79 10 9 12 11 53 27 60 26 101 39 102 41 115 43 126 44 16 Rofecoxib Mean SD (mins) 78 98 9 10 28 18 40 17 77 32 81 31 84 31 88 30 18

14

From this it is clear that rofecoxib improves the early recovery after outpatient herniorrhaphy.27 A prospective randomized double blinded study was designed to compare the use of ultrasonography with the conventional ilioinguinal / iliohypogastric nerve block technique. One hundred children (age range from 1month to 8 years) scheduled for inguinal hernia repair were included in the study. Following GA, the children received an ilioinguinal / iliohypogastric block performed either under ultrasound guidance using levobupivacaine 0.25% or by conventional fascial click method. Ultrasound guided ilioinguinal / iliohypogastric nerve blocks can be achieved with significantly smaller volumes of local anaesthetics, the intra and postoperative requirements for additional analgesia are significantly lower than conventional method.28 A prospective double blind randomized study was conducted to evaluate pain intensity in 36 ASAI-II out patients scheduled for elective day care inguinal heniorrhaphy, by performing inguinal field block (IFA) under GA with either 30 ml Bupivacaine 0.5% or with same volume of a mixture of 27 ml Bupivacaine (0.5%) + 3 ml s(+) ketamine (75 mg) or a 28 ml Bupivacaine (0.5%) + 2 ml ketamine or ketorolac only minimally improved the analgesic effect of Bupivacaine. This may be evaluated to the tension free hernia repair technique associated with low postoperative pain.29 In their study 160 patients found that the additional use of preoperative ilioin guinal field block (IFB) to well established step wise local infiltration anaesthesia procedure for inguinal hernia repair improves intraoperative pain relief, therefore recommended during unmonitored inguinal hernia mesh repair.30

15

ANATOMY OF INGUINAL CANAL No disease of human body, belonging to the province of the surgeon, requires in its treatment a better combination of accurate anatomical knowledge with surgical skill than hernia in all its varieties. (Sir Astley Paston Cooper, 1804)1 The inguinal canal contents : The inguinal canal is 4cm long and extends from internal inguinal ring laterally to the external inguinal ring medially. It lies above the inner half of the inguinal ligament.31 The canal gives passage to spermatic cord in male, and the round ligament of the uterus in the female.32 The deep ring, an oval opening in fascia transversalis, lies about 0.5 inch (1.3cm) above inguinal ligament midway between the anterior superior iliac spine and the symphysis pubis. Just medial to it is the inferior epigastric artery. The margins of the ring gives attachment to the internal spermatic fascia. The superficial inguinal ring, is a triangular defect in the aponeurosis of the external oblique muscle and lies immediately above and medial to pubic tubercle. The margins give attachment to the external spermatic fascia.33 The mid inguinal point is the midpoint of the line between anterior superior iliac spine and the symphysis pubis. Hence it is just medial to the midpoint of the inguinal ligament.

16

Boundaries of inguinal canal33 : 1) The anterior wall of the canal : Formed along its entire length by aponeurosis of the external oblique muscle. It is reinforced in its lateral third by the origin of the internal oblique. 2) The posterior wall of the canal : Formed along its entire length by fascia transversalis. It is reinforced in its medial third by conjoint tendon and reflected part of inguinal ligament. 3) The floor of the canal : It is formed by grooved surface of the inguinal and lacunar ligaments. 4) The root of the canal : Formed by arching lowest fibers of the internal oblique and transversus abdominis muscles. Contents of inguinal canal32 : 1) Spermatic cord in males and round ligament of uterus in female. 2) Ilioinguinal, iliohypogastric and genitofemoral nerves. Structures of the spermatic cord : 1) Vas deferens 2) Testicular artery 3) Cremastric artery 4) Artery of the vas deferens 5) Pampiniform plexus of veins 6) Testicular lymph vessels 7) Remnants of processus vaginalis 8) Autonomic nerves 9) Genital branch of genitofemoral nerve.

17

Coverings of the spermatic cord32 : From within outwards : 1) The internal spermatic fascia 2) The cremastric fascia 3) The external spermatic fascia. Protective mechanism for the development of hernia32 : 1) Canal is an oblique passage with weakest areas namely superficial and deep rings lying some distance apart. 2) Anterior wall is reinforced by the fibers of internal oblique 3) Posterior wall is reinforced by strong conjoint tendon. 4) On coughing and straining, the arching lowest fibers of the internal oblique and transverses abdominis muscle contracts so the canal is virtually closed. Abdominal hernia are of the following common types32 : Inguinal (indirect or direct) Femoral Umbilical (congenital or acquired) Epigastric Separation of recti abdominis Incisional hernias Hernia of linea semilunaris (spigelian hernia) Lumbar hernia (petits triangle hernia) Internal hernia

18

Fig. 1 : Inguinal field block anatomy47 (note that in the vicinity of anterior superior iliac spine, iliohypogastric nerve lies between internal and external oblique muscles. But ilioinguinal nerve lies between the transverses abdominis muscle and internal oblique muscles initially and then penetrates the internal oblique medial to anterior superior iliac spine).

19

Nerve supply : 1) Ilioinguinal nerve34: Origin : From L1 ventral ramus Course : It emerges from the lateral border of psoas major, with or just inferior to iliohypogastric nerve. It passes obliquely across quadratus lumborum and the upper part of iliacus and enters transversus abdominis near the anterior end of the iliac crest. It pierces internal oblique and supplies it and then traverses the inguinal canal below the spermatic cord. It emerges with the cord from the superficial inguinal ring to supply skin. Occasionally this nerve is completely absent, when the iliohypogastric nerve supplies its territory. Motor : Transversus abdominis and internal oblique. Sensory : Supplies sensory fibers to transversus abdominis and internal oblique. Medial skin of thigh and skin over the root of the penis and upper part of scrotum in males or skin covering the monspubis and adjoining labium majus in females. 2) Iliohypogastric nerve34 : Origin : L1 ventral ramus Course : It emerges from the upper lateral border of psoas major, crosses obliquely behind the lower renal pole, and in front of quadratus lumborum. Above the iliac crest, it enters the posterior part of transversus abdominis. Between transversus abdominis and internal oblique, it divides into lateral and anterior cutaneous branches. The lateral cutaneous branch runs through internal and external oblique above the iliac crest and is distributed to the posterolateral gluteal skin. The anterior cutaneous branch runs through internal oblique 2cm medial to anterior superior iliac spine, and through external oblique aponeurosis 3cm above superficial inguinal ring.

20

Motor : It supplies a small motor contribution to transversus abdominis and internal oblique, including conjoint tendon. Sensory : Supplies sensory fibres to transversus abdominis, internal oblique and external oblique, and innervates the posterolateral gluteal and suprapubic skin. 3) Genitofemoral nerve34 : Origin : Ventral rami of L1 and L2 Course : It is formed within the substance of psoas major and descends obliquely forwards through the muscle to emerge on the abdominal surface near its medial border, opposite the third or fourth lumbar vertebrae. It descends beneath the peritoneum on psoas major, crosses obliquely behind the ureter and divides above inguinal ligament into genital and femoral branches. The genital branch, crosses the lower part of external iliac artery, enters the inguinal canal by the deep ring. The femoral branch descends lateral to external iliac artery, then crosses deep circumflex iliac artery passes behind inguinal ligament and enters femoral sheath lateral to femoral artery. Motor : Cremaster muscle via genital branch of genitofemoral nerve. Cutaneous : Genital branch: skin of scrotum in males or monspubis and labium majus in females via genital branch. Femoral branch : Anteromedial skin of thigh.

21

PHARMACOLOGICAL ASPECTS OF LIDOCAINE Local anaesthetics belong to a surprisingly homogenous family of drugs that produce reversible conduction blockade of impulses along central and peripheral nerve pathways after regional anesthesia.35 All currently available clinically useful agents are either aminoesters or aminoamides. These drugs when applied in sufficient concentration at the site of action prevent the conduction of electrical impulses by the membranes of nerve and muscle.36 Cocaine was introduced as the first local anaesthetic in 1884 by Karl Kollar for use in ophthalmology. Hundreds of compounds have been synthesized since then and subjected to laboratory and clinical trials. Desirable character for an ideal local anaesthetic agents are37 : 1) Potent and effective in low concentration. 2) Wide and rapid spread with deep penetration of nerves. 3) Rapid onset of action. 4) Low toxicity i.e both systemic and tissue toxicity. 5) Non irritating ie, no nerve damage 6) Reversible action 7) Easily sterilized 8) Long duration of action 9) Compatibility with vasoconstrictor drugs 10) Solubility in cold physiologic saline 11) Lack of tachyphylaxis. Lidocaine though not an ideal local anaesthetic, still it comes closer to one. 22

Lidocaine produces more rapid, intense, and longer lasting conduction blockade than procaine. It is also effective topically and is a highly efficacious cardiac antidysrhythmic drug. For these reasons lidocaine is the standard to which all other anaesthetics are compared.35 Lidocaine was first synthesized by Nils Lofgren and Lunelqvist in 1943 in Sweden. It was first used by Gordh in 1948.31 Physiochemical property Lidocaine is the commonest used local anaesthetic of amide group. Chemical structure CH3 C2H5 NH CO CH2 N C2H5 CH3 Lidocaines chemical name is diethylamino 2, 6 acet oxylidide. It is essentially an amide resulting from the reaction of diethylamino acetic acid and xylene. Molecular weight : Base 234 Molecular weight of its hydrochloride salt is 270. It is freely soluble in water, the pH of 1% solution in 0.9% saline is 6.5 to 7.0. Stability : Lidocaine is very stable, it may be boiled for 8 hrs in 30% hydrochloric acid without decomposition or subjected to autoclaving for 6 hours without loss of potency.

23

Its Pka is 7.86; close to physiologic pH and moderate lipid solubility. Lidocaine also has excellent spreading capabilities. Lidocaine is an ideal agent for most block procedures in which rapid onset is required. Recommended concentration and clinical properties36 : Topical anaesthesia 2 to 4% is frequently used. 4% solution is effective for oropharynx, tracheobronchial tree and nose. 2% lidocaine jelly is available in a special tube with nozzle to permit application onto the patient end of endotrachial tube. 2.5 to 5% ointments are available for local anaesthesia of skin, mucus membrane and rectum. Infiltration anaesthesia : 0.5 to 1% solution with or without adrenaline result in an almost immediate blockade. The duration of block with plain lidocaine is 30-60 minutes and 120 minutes with lidocaine and adrenaline. A special application of 2% lidocaine with 1:1,00,000 adrenaline is commonly employed for infiltration in dentistry and ENT. Intravenous regional anaesthesia: Approximately 5 mg/kg (40 ml of a 0.5% solution) of preservative free lidocaine without adrenaline is used for upper extremity procedure. For surgical procedures on lower limb 50 to 100 ml of 0.25% lidocaine has been used. Peripheral nerve block : Minor nerve blocks are adequately performed with 0.5 to 1% lidocaine. 1% lidocaine has an onset of action within 5 minutes and lasts for 60 minutes with plain solution and 120 minutes with adrenaline containing solution.

24

Major nerve block with 1 to 2% lidocaine has an onset of action between 5 to 15 minutes and duration of 120-124 minutes with adrenaline (1:200,000). Epidural and caudal block: Sympathetic blockade is produced with 0.5% lidocaine. Sensory blockade with minimal motor blockade is produced by 1% lidocaine. Motor blockade of minimal degree is seen with 2% lidocaine solution, profound blockade with 2% lidocaine solution with 1:2,00,000 adrenaline. Onset of blockade occurs in 5 minutes, with complete blockade requiring approximately 20 minutes. Duration of action of plain lidocaine solution is approximately 60 minutes and this is extended to approximately 100 minutes with addition of adrenaline. Spinal anaesthesia : A hyperbaric 5% solution of lidocaine in 7.5% dextrose has a specific gravity of 1.035 at 370C and onset of action, almost immediate. The duration of action is 45 to 60 minutes with plain solution or 60-90 minutes with added adrenaline. Mechanism of Action36 : Solution of lidocaine when deposited near the nerve penetrates the nerve sheath. Then it permeates the nerves axon membrane. The binding of lidocaine to sites on voltage gated Na+ channel prevents opening of the channels by inhibiting the conformational changes that underlie channel activation. During onset and recovery, impulse blockade is incomplete and partially blocked fibers are further inhibited by repetitive stimulation. Clinically observed rates of onset and recovery from blockade are governed by relatively slow diffusion of molecule into and out of the whole nerve.

25

Active form of local anaesthetic molecule. R N + H+ (free base) RNH (cation)

In order to act the drug must first penetrate surrounding tissue and nerve sheath. Only uncharged form can gain access to cell membrane. Once it penetrates, it is the cation form that is responsible for nerve blocking action. Carbonated form of lidocaine is more effective than hydrochloride form. CO2 is released which diffuses into interior of cell in carbonated form, decreases the pH and increases the ionization, thus decreasing the concentration of base and increasing gradient for diffusion. Pharmacokinetics and metabolism : Partial co-efficient : 2.9 Protein binding : 64% Apparent volume distribution, Vd : 110 ltr. With values mentioned above, lidocaine falls into category of rapid onset, moderately potent agent with intermediate duration of action. At 1 to 4 g/ml lidocaine is 70% protein bound and at 12 g/ml only 30% protein bound near saturation, toxicity increases with increase in non bound fraction. Metabolism : The disposition of lidocaine is mainly by biotransformation. It is accomplished in liver by microsomal mixed function oxidases. The initial reaction is dealkylation of lidocaine to monoethylglycine xylidide(MEGX) and then to 2-6, xylidine. 2,-6 xylidine is further metabolized by hydroxylation of its ring structure to form 4 hydroxy 2, 6 xylidine. The conjugate of

26

this product is the major urinary metabolite. Approximately 73% of given dose is eliminated in urine in this form. A minor pathway of transformation is to glycide-xylidide (GX) from MEGX forming an additional urinary fraction of conjugated GX. Approximately 3% is excreted unchanged.37 Pharmacodynamics : The effects produced may be : a) Local-nerve blockade of direct effect in smooth muscle. b) Regional block loss of pain, temperature, touch, pressure sensation and loss of vasomotor tone in the region supplied by nerve blockade. Systemic effect : Cardiovascular system lidocaine exerts a membrane stabilizing effect with an anti arrhythmic effect on ventricular arrhythmia. Lidocaine decreases the rate of depolarization in fast conducting tissues of purkinje fibres and ventricular muscle. At extremely high concentration lidocaine may depress sino-atrial node and lead to bradycardia. Lidocaine exerts a dose dependent negative inotropic action on cardiac muscle. Lidocaine inhibits cardiac sarcolemmal Ca2+ currents as well as Na+ currents. Lidocaine has a biphasic effect on peripheral vascular smooth muscle. Low concentration produces vasoconstriction in cremaster muscle of rats and high concentration cause vasodilatation. Hypercapnia, acidosis and hypoxia potentiates negative chronotropic and inotropic action of lidocaine on isolated cardiac tissue.

27

Central nervous system : Both excitation and depressant actions on CNS are observed. Excitatory effect of CNS involves concept of selective neuronal blockade with depression of inhibitory pathways at low plasma concentration leaving exciting neurons to function unopposed. Respiratory and metabolic acidosis increases the risk of CNS toxicity. Ventilatory response to carbondioxide : At 3-4 g/ml lidocaine increases sensitivity of medullary respiratory centre to CO2 and slope of CO2 response curve shifted to left. At 8-10 g/ml sub convulsive level it produces ventilatory depression and flattening of CO2 response curve. Effects on skeletal muscle: Lidocaine causes extrusion of calcium from sarcoplasmic reticulum. Wound healing : Concentration of lidocaine commonly injected into tissue significantly inhibit phagocytosis and metabolism of human leucocytes in vitro. Safe dose : Maximum safe dose in man would be 7 mg/kg with adrenaline and 3 mg/kg without adrenaline. Toxic symptoms may occur at plasma levels of 3-5 g/ml.37 Toxicity : Lidocaine toxicity chiefly effects cardiovascular and central nervous

system with effects on latter preceeding cardiovascular manifestation. CVS : Initial stimulation results in hypertension and tachycardia followed by depression.

28

Depressant stages : Primary : Negative inotropism hypertension. Secondary : Peripheral vasodilatation leading to marked reduction in cardiac output and profound decrease in BP. Tertiary : Sinus bradycardia conduction defect, cardiac arrhythmias. Treatment : 1) Prophylaxis : Use correct amount necessary to block the nerve. Use dilute solution as far as possible. Aspirate before injection to rule out intravascular injection. Use vasoconstrictors. leading to reduced cardiac output and mild

2) For convulsions : Intravenous Thiopentone or Diazepam plus 100% O2 inhalation. 3) For respiratory failure : Artificial respiration 4) For circulatory arrest : Restoration of blood pressure with sympathomimetics (ephedrine,

phenylephrine or methoxamine) and fluid administration. 5) For cardiac arrest : Cardiac massage and artificial respiratory and supportive measures.

29

CC/CNS ratio : CC/CNS Ratio is the dose required for irreversible cardiac collapse and dose required to produce CNS toxicity. CC/CNS dose ratio for lidocaine : 7.1 1.1. CC/CNS blood level ratio for lidocaine : 3.6 0.3.

30

Methodology

METHODOLOGY
A clinical study was undertaken for anaesthetising in 50 patients aged between 18-60 years posted for elective inguinal hernia repair, agreeing and co-operative for inguinal field block. Study was conducted at Chigateri General Hospital and Bapuji Hospital attached to J.J.M. Medical College, Davangere during the period of September 2005 to august 2007. Selection of patients : Inclusion criteria : Normal adults between 18-60 years age belonging to ASA Grade I and ASA Grade II coming for elective inguinal hernia repair without any associated diseases. Exclusion criteria : Patients below 18 and above 60 years. Patients with ASA Grade III and ASA Grade IV. Presence of ischemic heart diseases, hypertension, symptomatic asthma, inability to climb a flight of stairs, brittle diabetes, uncontrolled epilepsy, renal problems, bleeding disorders, patients on chronic drug medications such as MAO inhibitors, acute substance abuse, previous problem with anaesthesia, obesity, neurological deficit, peripheral nerve injury, infection at operative site and patients unwilling to comply with instructions. Pre-anaesthetic evaluation : Pre-anaesthetic evaluation was done a day prior to the elective surgery. History of present complaints, duration of swelling and any co-existing disease, previous surgery etc. are noted. A thorough physical, systemic examination was done

31

which included the size of the swelling, type of hernia, weight of the patient, vital signs, airway assessment etc. The following investigation were carried out in all patients : Hb%, bleeding time, clotting time, blood urea, serum creatinine, random blood sugar, urine for routine examination, ECG and chest x-ray for patient above 45 years. All patients were assessed and they are graded according to the ASA physical status I and II. They were educated regarding the anaesthetic technique. Consent for the same was obtained. Local anaesthetic test dose for Lidocaine was carried out on the previous day of surgery. Patients were premedicated with oral Diazepam 10 mg and Pantoprazole 20 mg at night. Regional anaesthetic equipment : There are several important requisites for optimal results in regional anaesthesia. In order to have consistently good results, the anaesthesiologists must have a genuine interest in and be convinced of the advantages of regional anaesthesia. After attaining the necessary skill and clinical application, thorough knowledge of the pertinent anatomy and landmarks, familiarizing with the pharmacology of the local anaesthetic agents as well as the physiological changes that accompany these anaesthetics. He can thus anticipate any changes and be prepared to institute immediate treatment if necessary (i.e. intravenous fluids, Atropine and possible vasopressors). Equally important is the careful preparation and management of the individual patient and the availability of appropriate anaesthesia equipment as well as equipment for resuscitation and the treatment of adverse reactions. The department of anaesthesiology in which regional anaesthesia is to be performed in a sophisticated fashion must have a significant inventory of regional 32

anaesthesia equipment. Although not absolutely essential, it is certainly both desirable and convenient to have carts designated exclusively for use in regional anaesthesia. The cart should be lightweight, mobile and have at least shelves with dimensions approximately 45 to 68 cms. The top shelf is reserved for the regional anaesthesia tray being used, but the two lower shelves allow storage of other block trays, commonly employed local anaesthetic agents, needles, syringes, catheters, preparation solution, tape gloves, etc. Block trays : Depending upon the preference of the anaesthesiologist, disposable, commercially prepared for reusable, department prepared block trays may be used. The department prepared block trays must be meticulously assembled by conscientious, well trained workers, with care being taken to prevent chemical and bacterial contamination. Thus, these block trays are more versatile and have the added advantage of satisfying the personal preferences of the anaesthesiologist. Local anaesthetic agents with or without adrenaline depending on the need of the regional anaesthetic technique must be kept ready. Needles : A wide selection of high quality needles of various lengths, gauges and kinds of bevel should be available. Needles for peripheral nerve blocks should be sharp, free of barbs and short bevelled. Traditionally, needles for Ilioinguinal-hypogastric nerve blocks have been predominantly 22 or 25 gauge in diameter, 12-15 cm in length, ideally spinal needle is used.

33

Syringe : Disposable or glass barrel syringes with close fitting plungers and finger control and various sizes ranging from 2ml, 5ml, 10ml, 20ml, etc. are kept ready. Resuscitation : After securing a peripheral intravenous line with a cannula and appropriate monitoring. To perform block, equipments and drugs for resuscitation and treatment of complications should be immediately available. This should include a means of administering oxygen by positive pressure, such as an anaesthesia machine or an resuscitation bag and mask connected to a source of oxygen, airway equipment, working laryngoscope, oropharyngeal airways of several sizes, cuffed endotracheal tubes of appropriate sizes, a suction catheter connected to wall suction and labelled syringes that contain ultra short acting Barbiturate, Diazepam, Succinylcholine, atropine and a dilute solution of vasopressors (Ephedrine 5-10 mg/ml). PREMEDICATION AND MONITORS : . On the day of surgery an IV line was secured with no. 20 G IV Cannula. The monitors pulse oximeter, ECG, NIBP were connected. Premedication Inj. Midazolam 2 mg IV was administered.

34

Fig. 2 : Inguinal block anatomy and technique47

Fig. 3 : Inguinal block cross sectional anatomy and technique47

35

Procedure of Field Block for Inguinal Hernia Repair : Under strict aseptic precautions with patient in supine position, first the anterosuperior iliac spine was identified. A skin wheal is made just half an inch medial to the anterosuperior iliac spine in the spinoumbilical line. A 23 G spinal needle was fixed to a syringe containing 15 ml of 1% lidocaine with adrenaline. The needle was then directed perpendicular to the skin through the skin wheal already made. As the needle was advanced first give was felt when needle passed the external oblique muscle. The second give was felt when the needle passed the internal oblique muscle. The needle was just above transversalis fascia through which ilioinguinal nerve and iliohypogastric nerves traverse where 15 ml of 1% lidocaine was injected in a fan shaped manner here. A second wheal was made over the pubic tubercle with syringe containing 5 ml of 1% lidocaine with adrenaline directed perpendicularly through the wheal until pubic tubercle was contacted. The needle was then walked off the pubic tubercle in cephalad direction until the cartilagenous structure known as Coopers ligament was contacted. The solution was then injected into and along this structure. A third skin wheal was raised 0.5 cm above the mid point of the inguinal ligament and 5 ml of 1% lidocaine was injected through this skin wheal to a depth of 3 cm, aspirating for blood from the inferior epigastric artery, which might come in the way. This was to block genital branch of genitofemoral nerve. Then by using 10 ml of 1% lidocaine a subcutaneous infiltration was done along the line of incision, spino-umbulical line and from pubic tubercle to umbilicus to block crossover fibres. The maximum dose of lidocaine with adrenaline to be given was 7 mg / kg which was kept in mind. A minimum of 10 minutes was allowed after

36

the block, in this study. Whenever the patient complained of pain, at the neck of sac 2 ml of 1% lidocaine with adrenaline administered. At the time of hernia repair a sedative dose of propofol was administered to all patients. In the present study the following scale was adopted to grade analgesia and relaxation. 1. Excellent : Patient comfortable, analgesia, and surgical relaxation adequate, no supplementation required during surgery. 2. Good : Analgesia and relaxation adequate, minimal discomfort present during surgical procedure. This could be alleviated by supplementary local anaesthetic agent at the neck of sac. 3. Fair : Analgesia and relaxation adequate, in addition to infiltration of the sac patients needed a narcotic supplementation. (Inj. Fentanyl). 4. Poor : Patients complaining of severe intolerable pain during surgery without relaxation. These cases were converted to general anaesthesia. Blood pressure, heart rate, oxygen saturation, ECG, monitoring were done every 5 minutes till the end of surgery. Duration of surgery and analgesia, were noted. The signs, symptoms of local anaesthetics toxicity were observed. Then after the surgery, a) Patient post anaesthesia recovery were assessed in operation room (OR) by criteria used to determine fast-track eligibility after ambulatory anaesthesia. b) The postoperative pain relief and post-anaesthetic complications monitored.

37

TABLE 3 : CRITERIA USED TO DETERMINE FAST-TRACK ELIGIBILITY AFTER AMBULATORY ANAESTHESIA36 Criteria Able to move all extremities on command Physical activity Some weakness in movement of the extremities Unable to voluntarily move the extremities Respiratory stability Able to breathe deeply Tachypnea with good cough Dyspneic with weak cough Blood pressure <15% of the baseline MAP value Hemodynamic Stability Blood pressure between 15% and 30% of the baseline MAP value Blood pressure >30% below the baseline MAP value Level of Consciousness Awake and oriented Arousable with minimal stimulation Responsive only to tactile stimulation Oxygen Saturation Status Maintains value >90% on room air Requires supplemental oxygen (nasal prongs) Saturation <90% with supplemental oxygen Postoperative Pain Assessment None or mild discomfort Moderate to severe pain controlled with IV analgesics Persistent severe pain Postoperative emetic symptoms Total score None or mild nausea with no active vomiting Transient vomiting or retching Persistent moderate to severe nausea and vomiting Score 2 1 0 2 1 0 2 1 0 2 1 0 2 1 0 2 1 0 2 1 0 14

The mentioned score is assessed for 30 min, with interval of 15 min after the surgery. Once the patient achieves a score of 12 or more, patient is ready to be shifted directly to wards bypassing the post anaesthesia recovery room. The total duration of analgesia (the duration of onset of analgesia till the subjective compliant of pain) assessed in all the patients.

38

STATISTICAL ANALYSIS : Descriptive data included mean, standard deviation and percentage which were determined for the study group.

39

Photograph 1 : Materials used for field block for inguinal hernia repair

Photograph 2 : Reducible indirect inguinal hernia

40

Photograph 3 :Administration of local anaesthetic agent to a point half an inch medial to ASIS along spino-umbilical line

Photograph 4 :Administration of local anaesthetic agent to a point medial to pubic tubercle

41

Photograph 5 :Administration of local anaesthetic agent to a point 0.5cm above the mid point of the inguinal ligament

Photograph 6 :Subcutaneous infiltration of local anaesthestic agent along the line of incision

42

Photograph 7 :Subcutaneous infiltration of local anaesthestic agent along spino-umbilical line

Photograph 8 :Subcutaneous infiltration of local anaesthestic agent from pubic tubercle to umbilicus

43

Results

RESULTS
TABLE 4 : AGE DISTRIBUTION Age group (yrs) 18-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 Total Table 4 shows total age distribution of patients. Mean age : 39.36 STD Deviation : 12.6826 Majority of the patients were in 18-30 years and 51-60 years. Number of Patients 9 8 5 6 4 4 7 7 50

GRAPH 1 : AGE DISTRIBUTION

9 9 8 No. of patients 7 6 5 4 3 2 1 0
1 8-25 26-30 31 -35 36-40 41 -45 46-50 51 -55 56-60

8 7 6 5 4 4 7

Age group (yrs)

44

TABLE 5 : SEX DISTRIBUTION Male 50 Table 5 Shows total sex distribution of patients TABLE 6 : WEIGHT DISTRIBUTION Weight in kg 51-60 kg 61-70 71-80 81-90 Total Number of patients 26 21 2 1 50 Female 0

Table 6 Shows the weight distribution of patients. Maximum weight was 85 kg and minimum weight was 51kg. Mean weight 60.74 kgs with a standard deviation of 7.21905

GRAPH 2 : WEIGHT DISTRIBUTION

30 25 No. of patients 20 15 10 5 0

26 21

51-60

61-70

71-80

81-90

Weight (kg)

45

TABLE 7 : TYPE OF HERNIA Direct Number of patients 16 Indirect 34

Table 7 Shows total number of hernia. Direct -16 Indirect- 34

GRAPH 3 : TYPE OF HERNIA

16 Direct Indirect 34

46

TABLE 8 : VOLUME OF LIDOCAINE 1% WITH ADRENALINE USED Volume No. of patients 35ml 38 37 ml 12

Lidocaine with adrenaline used for field block : Mean volume used 35.48ml Maximum dose allowed 37ml Minimum dose allowed 35ml

GRAPH 4 : VOLUME OF LIDOCAINE 1% WITH ADRENALINE USED

12

35ml 37 ml

38

47

TABLE 9 :QUALITY OF ANALGESIA AND RELAXATION No. of patients Excellent Good Fair Poor Total 36 8 4 2 50 Percentage 72 16 8 4 100

Table 9 Shows quality of analgesia and relaxation of patients 36 patients had a excellent type of analgesia and relaxation. 8 patients complained of discomfort during surgical handling of the hernial sac or hernia repair. To alleviate this 2ml of 1% lidocaine with adrenaline was injected at the neck of the sac. 4 patients were not comfortable with the above measures and needed fentanyl depending upon their body weight. 2 patients had no analgesia at all, so general anaesthesia was instituted with propofol induction and suxomethonium facilitated intubation and maintained with O2 + N2O narcotic technique + muscle relaxant + controlled ventilation.

GRAPH 5 : QUALITY OF ANALGESIA AND RELAXATION

80 70 60 Percentage 50 40 30 20 10 0

72

16 8 4

Excellent

Good

Fair

Poor

48

TABLE 10 : DURATION OF SURGERY Duration of surgery in minutes 20-30 30-40 40-50 50-60 Total Number of patients 1 27 18 4 50

Table 10 Shows duration of surgery in min. Mean duration of surgery 39.54 minutes Minimum duration 28 minutes Maximum duration 60 minutes

GRAPH 6 : DURATION OF SURGERY

30 25 No. of Patients 20 15 10 5 0 20-30 1

27

18

30-40

40-50

50-60

Duration of surgery (m in)

49

TABLE 11 : DURATION OF ANALGESIA Time range in minute No analgesia 151-160 161-170 170-180 181-190 191-200 201-210 211-220 221-230 231-240 241-250 251-260 261-270 271-280 281-290 291-300 Total Number of patients 2 1 4 4 3 6 7 12 2 3 1 1 2 2 50

Table 11 Shows duration of analgesia in minutes. The patients who received general anaesthesia, had no analgesia Mean duration 201.02 min Minimum duration 160 min Maximum duration 280 min
CHART 7 : DURATION OF ANALGESIA
291 -300 281 -290 271-280 261-270 251-260

0 0 2 2 1 1 3 2 12 7 6 3 4 4 1 2 0 2 4 6 8 Percentage 10 12 14

Time range (min)

241-250 231 -240 221 -230 211 -220 201-210 191 -200 181-190 1 70-180 161-170 151-160 No analgesia

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TABLE 12 : MEAN HEART RATE CHANGES Heart rate Pre-operative 0 minutes 5 minutes 10 minutes 15 minutes 20 minutes 30 minutes 45 minutes 82.92 89.14 85.6 84.26 84.12 84.66 82.56 83.6 Standard deviation 10.63656 10.1 9.72 14.42 7.07 15.1 7.06 6.23

Table 12 Shows mean heart rate changes in beats per minute. Initially, immediately after the block 6 beats was the mean heart rate increase. This increase was 3 beats at 5 minutes, 1 beats at 10 minutes, 1 beats at 15 minutes, 2 beats at 20 minutes, 1 beat at 30 minutes, 0 beats at 45 minutes compared to pre-operative heart rate.

GRAPH 8 : MEAN HEART RATE CHANGES

90 89 88 87 86 85 84 83 82 81 80 79 89.14

Mean Heart Rate

85.6 84.26 82.92 84.12 84.66 83.6 82.56

Preoper at ive

0 min

5 mins

10 mins

15 mins

20 mins

30 mins

45 mins

Tim e (m in)

51

TABLE 13 : MEAN BLOOD PRESSURE CHANGES Systolic BP mmHg Pre-operative 0 minutes 5 minutes 10 minutes 15 minutes 20 minutes 30 minutes 45 minutes 124.72 130.7 123.88 119.58 119.24 119.76 118.7 119.72 Diastolic BP mmHg 77.82 81.88 77.32 74.58 75.4 75.32 75.32 76.64 Mean arterial pressure mm Hg 93.45 98.15 92.84 89.58 90.01 90.13 89.78 91

Table 13 Shows mean systolic and diastolic blood pressure changes. Systolic blood pressure, diastolic blood pressure as well as the mean arterial blood pressure was maintained within 5-10 % range.

GRAPH 9 : MEAN BLOOD PRESSURE CHANGES

140 Blood Pressure (mm of Hg) 120 100 80 60 40 20 0
P reo perative 0 min 5 mins 1 mins 0 1 mins 5 20 mins 30 mins 45 mins

Tim e (m in)

Systolic BP mmHg

Diastolic BP mmHg

Mean arterial pressure mm Hg

52

TABLE 14 : SPO2 CHANGES Preoperative 0 minutes 5 minutes 10 minutes 15 minutes 20 minutes 30 minutes 45 minutes 98.46 98.18 98.44 98.14 98.4 98.16 98.4 98.16

Table 14 Shows SpO2 maintained with in 98.29 0.15.

GRAPH 10 : SPO2 CHANGES

Preoperative 98.16 98.4 98.46 98.18 0 min 5 mins 10 mins 15 mins 98.16 98.4 98.14 98.44 20 mins 30 mins 45 mins

53

TABLE 15 : INTRAOPERATIVE COMPLICATIONS Nil

TABLE 16 : ANALGESIA AND RELAXATION (SUCCESS RATE) Percentage Excellent Good Fair Poor 72 16 8 4 96%

Success rate 96%, Failure rate 4%

GRAPH 11 : ANALGESIA AND RELAXATION (SUCCESS RATE) 96 100 80 Percentage 60 40 4 20 0 Success rate Failure rate

54

TABLE 17 : RECOVERY SCALE Criteria used to determine fast-track eligibility after ambulatory anaesthesia PARAMETER 1 : PHYSICAL ACTIVITY Time 0 minutes 15 minutes 30 minutes Mean score 2 2 2 Standard deviation 0 0 0

That means all the patients who had field block for inguinal hernia repair were able to move all the 4 extremities on command. TABLE 18 PARAMETER 2 : RESPIRATORY STABILITY Time 0 minutes 15 minutes 30 minutes Mean score 2 2 2 Standard deviation 0 0 0

All the patients were able to breath deeply TABLE 19 PARAMETER 3 : HAEMODYNAMIC STABILITY Time 0 minutes 15 minutes 30 minutes Mean score 2 2 2 Standard deviation 0 0 0

All the patients were able to maintain blood pressure within less than 15% of the baseline MAP value.

55

TABLE 20 PARAMETER 4 : LEVEL OF CONSCIOUSNESS Time 0 minutes 15 minutes 30 minutes Mean score 1.96 1.96 1.98 Standard deviation 0.2 0.2 0.14

48 patients were awake and oriented throughout, but 2 patients who received general anesthesia were arousable with minimal stimulation. TABLE 21 PARAMETER 5 : OXYGEN SATURATION STATUS Time 0 minutes 15 minutes 30 minutes Mean score 2 2 2 Standard deviation 0 0 0

All the patient were able to maintain O2 saturation value > 90% on room air . TABLE 22 PARAMETER 6 : POST OPERATIVE PAIN ASSESSMENT Time 0 minutes 15 minutes 30 minutes Mean score 2 2 2 Standard deviation 0 0 0

48 patients were pain free, but 2 patients who received general anesthesia complained of mild discomfort.

56

TABLE 23 PARAMETER 7 : POST OPERATIVE EMETIC SYMPTOMS Time 0 minutes 15 minutes 30 minutes Mean score 1.96 2 2 Standard deviation 0.2 0 0

48 patients had no emetic symptoms, But 2 patients who received general anesthesia had transient vomiting or retching at 0 min. TABLE 24 PARAMETER 8 : TOTAL SCORE Time 0 minutes 15 minutes 30 minutes Mean score 13.92 13.96 13.98 Standard deviation 0.396 0.198 0.141

TABLE 25 : NUMBER OF PATIENTS ACHIEVE FAST TRACK ELIGIBILITY SCORE OF 12 AND ABOVE Time 0 minutes 15 minutes 30 minutes Number of patients 48 50 50

All the patients had a score of 12 at 0 min, all of them had a score of >12 at 15 min and 30 min. All the patients were ready to be shifted to ward bypassing the post anaesthesia recovery room. 57

GRAPH 12 : FAST TRACK ELIGIBILITY SCORE OF 12 AND ABOVE

50

48 0 min 15 mins 30 mins

50

58

Discussion

DISCUSSION
Inguinal hernia repair is one of the most commonly encountered surgical correction in men representing 12.5% of total surgical repair in Britain. In the international classification of diseases 9th division clinical manifestation, the number was 9 for hernias with relative value guide of 6.38 In providing anaesthesia for inguinal herniorrhaphy, the technique choosen must be most cost effective with respect to speed of recovery, patient comfort, and associated incremental costs.3 The safety and effectiveness of hernia repair using local anesthesia is more in teaching hospitals because of low cost.22 The advantage of local anesthesia are safety, simplicity, effectiveness2, cost effective, low rate of recurrence and infection.17 It is a method of choice in out patient surgery and for minimizing the cost of surgery. Any patients with hernia, a field block will reduce the anaesthetic risk to a minimum, allow immediate ambulation and food intake, reduce postoperative complications such as urinary retention, atelectasis and phlebitis, and almost eliminate the need for post operative narcotic analgesia.7 Large series of studies are available in surgical and anaesthesia literature regarding the usage of field block for inguinal hernia repair. Most of these were with general anaesthesia or neuraxial anesthesia or monitored anaesthesia care under deep sedation. But the search of literature does not reveal any studies which have utilized field block as a sole anaesthetic agent with lidocaine and adrenaline for inguinal hernia repair.

59

In view of the above, the present study was undertaken to investigate field block for inguinal hernia repair using 1% lidocaine with adrenaline. In the present study 50 patients of ASA class I and II posted for elective inguinal hernia repair were studied using the above technique. A study stated that rate of admission was 2.9% in ASA class III compared to 1.9% in class I and II patients. They suggested that the patients with ASA class III can be treated safely, only after good pre-operative assessment and adequate preparation.39 We have selected only ASA class I and II patients for our study. Many authors have used lidocaine alone for inguinal field block7,10, but it is short acting. Followed by that, some authors added epinephrine to lidocaine for the block because epinephrine reduces plasma concentration of lidocaine, minimizes toxicity and also prolonged post operative pain relief.15 Some authors who used the above combination for institution of block found that there was an improvement in quality and duration of block.26 In surgical patients it may be postulated that C afferent fibers activity may be generated not only intraoperatively but also post operatively, partly as result of persistent inflammation and hyperalagesia at wound site which is affected by using lidocaine with adrenaline15 hence we have used the combination of lidocaine with adrenaline in our study. Concentration of lidocaine with adrenaline solution : In earlier times the surgeon who themselves acted as anesthesiologists administered fixed dose of the drug, without considering the weight of the patient. But

60

today anaesthesiologist uses a calculated dose of local anaesthetic to avoid the toxicity. The below mentioned table shows the volume of lidocaine with adrenaline used in three studies. TABLE 26 : VOLUME OF LIDOCAINE WITH ADRENALINE USED IN THREE STUDIES Study Total volume ASIP MPI PT SC Neck of the sac Earle AS (1960)40 Dierking et al (1992)15 Dunn J et al (1994)41 Present study 34-40 ml (0.5%) 55ml (15-ml 1% + 40 ml 0.5%) 42ml (1%) (60-70 kg) 35-37 ml 15ml 5ml 5ml 10ml 2ml 25ml 5ml 5ml 20ml 5-10ml 3.5ml 5-20ml 2ml

The present study was the combination of the above studies and utilized a mean volume 35.48 ml of the drug. Dosage and concentration of lidocaine with adrenaline : Vasomotor effects of lidocaine often resulted in diverse changes in local blood flow, little reduction occurring with 0.5% lidocaine usage, but becoming apparent when 1-2% of the drug is used.26 In our study we have used 1% lidocaine combine with adrenaline. It has been suggested that upper limit for lidocaine with adrenaline is 7mg/kg.36

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As a fairly large volume of drug was required for the block, the concentration kept at 1% for lidocaine with adrenaline in our study. The mean weight of our patients 60.74 kg and mean volume used is 35.48ml, it become clear that the total dose of the lidocaine employed by us is well within the upper recommended limit. Quality of analgesia and relaxation : Most of the authors have not commented regarding the quality of analgesia in the field block even though they carried out surgery under local anesthesia. A study demonstrated good quality of analgesia could be achieved by ilioinguinal nerve block.11 In the present study we graded 36 patients had excellent analgesia and relaxation, i.e. patient comfortable, analgesia and surgical relaxation adequate no supplementation is required during surgery. Only 8 patients had good analgesia and mild discomfort during sac manipulation which required supplementation. With additional infiltration around the neck of the sac with 2ml of lidocaine 1% with adrenaline. 4 patients had analgesia graded as fair with mild pain during surgery. These patients were given fentanyl 1-2 g/kg to alleviate the pain. 2 patients (4%) had severe intolerable pain during surgery, requiring conversion to general anaesthesia. It has been observed by various authors that at the time of traction on the sac, patients often complain of discomfort.13,40 This finding was observed in 8 patients in our present clinical study. Some authors used narcotic for pain relief during surgery.3,42 In the present study 4 patients require narcotics in additional to local anaesthetic supplementation.

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A study stated that use of sedative dose of propofol has advantage of less nausea and vomiting, because of antiemetic action which in turn results in faster recovery and cost effectiveness.20 Some study stated that some sedation during the operation may be required for anxious patients which loses some of the benefits of avoiding general anaesthesia. Patients who are excessively nervous may be unsuitable for surgery under local anaesthesia.41 In our study we used propofol at a dose of 25mg at the time of inguinal hernia repair. A study was conducted in 400 hernia patients who underwent surgery under local anaesthesia in whom 0.5% were converted to general anaesthesia.18,19 In our study, 2 patients (4%) required general anaesthesia. Duration of surgery and analgesia : In present study all inguinal hernia repair were completed within 60 minutes. TABLE 27 : DURATION OF SURGERY Dierking GD (1992)15 Twerskoy MC (1990)13 Present study 48 (25-90) minutes 31 5 minutes 39.54 min (28-60 min)

Present study is in between the duration of the above two studies. Many studies did not mention about duration of analgesia, but many worker have shown that prolonged post operative pain relief after ilioinguinal/ ilio hypogastric nerve block.11 Epinephrine enhances the degree and extends the duration of lidocaines peripheral nerve block.26

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As per Covino et al43, the duration of analgesic effect of lidocaine is 195 minutes 26.3 min for brachial plexus block, for local infiltration 75 min (35-340 min), duration can be prolonged up to 20% by addition of epinephrine. In the present study mean duration of analgesia was 201.02 minutes (160 min 280min). So the present study correlates with studies done by Covino et al. Haemodynamic stability : Local anaesthesia for inguinal hernia repair causes minimal physiological disturbance. This may be particularly useful for patients with cardiovascular and respiratory diseases.41 In our present study, mean heart rate increase was 3 beats at 5 min, 1 beat at 10 min, 1 beat at 15 min, 2 beat at 20 min, one beat at 30 min. Systolic blood pressure, diastolic blood pressure as well as mean blood pressure was maintained within 5-10% range. O2 saturation showed nil to minimal changes over perioperative period. So clinically, hemodynamic stability as assessed by heart rate, blood pressure and oxygen saturation were maintained in all the 50 patients. After the surgery post anaesthesia recovery was assessed. Fast track scoring system takes into consideration, pain, emetic symptoms, as well as Aldretes assessment of consciousness, physical activity, hemodynamics and respiratory stability. The new fast track scoring system seems to offer advantages over the modified Aldretes scoring system in evaluating the suitability of patients for bypassing PACU after undergoing ambulatory surgery with general anaesthesia.44

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In a study author used fast track eligibility criteria for all the patients leaving the operation room (OR), to assess the recovery at every 30 min interval for meeting the criteria for discharge home from day surgery unit.3 So in our present study, we have used fast track eligibility criteria for assessing post anaesthesia recovery after surgery for 30 min at every 15 min interval, to meet the criteria to shift the patients to ward bypassing the recovery room. The following are the studies done by various authors for hernia repair under field block or monitored anaesthesia care as ambulatory anaesthesia. TABLE 28 : VARIOUS STUDIES FOR HERNIA REPAIR UNDER FIELD BLOCK OR MONITORED ANAESTHESIA Year Study 1994 Ding Y et al16 Kark AE et al17 Procedure Result MAC with Ambulation time 86 18 minutes field block 1995 Field block Fit for discharge 112 49 minutes Able to walk to the room assisted by nurse after 1.5 hrs but fully able to walk within 3 hours. Post-operative 2000 2000 Ezio G et al22 Song D et al3 Local anesthesia IHNB-MAC + All patients were transferred directly propofol 2002 Apfelbaum JL et al
45

wound

pain

1%,

Haematoma 1%, Urinary retention nil. Hospital stay ranges 3 hrs to 14 days.

from operation room to phase II recovery unit. with Mean 90 minutes as a recovery time. Recovery range 20 minutes to 210 minutes. General anaesthesia : 90 minutes to 270 minutes.

MAC

field block

2004

Hangma et al

27

Field block + The details are given below : Propofol

65

Number of patients Age Sex Weight ASA physical status I / II / III Surgery time Anaesthesia time Propofol (mg) Local anaesthetic Recovery profile Eye opening (minutes) Responds to commands Orientation Sitting up Tolerate oral fluids ( minutes) Standing up Ambulating Home readiness

30 43 14 years 26/4 M/F 71 9 kg 22/8/0 42 15 minutes 49 15 minutes 351 218 minutes 34 12 ml Time (minutes) 79 10 9 12 11 53 27 60 26 101 39 102 42 115 43

Physical activity : All the patients after surgery were able to move all the four extremities with out any limitation of movements. The present study correlates Kark AE et al 1990.17

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Respiratory stability : Local anaesthesia does not affect respiration so patients were able to cough freely and able to breath deeply. Haemodynamic stability : Local anaesthesia does not affect circulation as it produces no alteration in physiological status. All the patients were able to maintain blood pressure within 15% of the baseline MAP value. Level of consciousness : During assessment 48 patients were awake and fully oriented throughout, but two patients who received GA were arousable with minimal stimulation. Oxygen saturation status : All the patients were able to maintain saturation value of > 90% on room air. because ours is a regional technique and causes nil or minimal alteration in physiological state. Post operative pain assessment : In our study 48 patients were pain free, but two patients who received GA complained of mild discomfort. Post operative emetic symptoms : In our study 48 patients had no emetic symptoms but two patients who received GA had transient vomiting and retching at 0 minutes. Fast track eligibility criteria recovery score : All the patients had a score of 12 at 0 minute, all of them had a score of > 12 at 15 min and 30 min. All the patients were ready to be shifted to ward room 67

bypassing the post anaesthesia recovery room, similar to the study done by Song D et al.3 Side effects pertaining to the inguinal field block : In a study involving 41 patients who underwent inguinal hernia repair with local anaesthesia two complications were recorded. One patient developed wound infection, and one patient developed wound hematoma.46 In our study out of 50 patients who underwent inguinal hernia repair, no such complications were recorded.

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Conclusion

CONCLUSION
1) Duration of analgesia is good by using 1% lidocaine with adrenaline. 2) Field block is found to be safe and fulfills the requirements of surgical relaxation with minimal alteration in physiological homeostasis. 3) Lidocaine with adrenaline is effective for carrying out field block for inguinal hernia repair and provides long duration of post-operative pain relief. 4) Field block is the best method as far as recovery profile is concerned. 5) Field block for inguinal hernia repair avoids polypharmacy, is safe, economical, with rapid recovery when compared to neuraxial blockade and general anaesthesia. 6) Field block for inguinal hernia repair results in minimal or no complications. 7) This technique can be used safely in patients with respiratory or cardiovascular diseases.

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Summary

SUMMARY
A clinical study was undertaken at the Department of Anaesthesiology, J.J.M Medical College, Davangere to evaluate the effectiveness of 1% lidocaine with adrenaline for field block for inguinal hernia repair a clinical study. The study population consisted of 50 patients of ASA class I and II. All the patients were explained about the procedure and anesthetic technique and consent for the same obtained. Local anaesthetic test dose was carried out on previous day. Patients received oral tab Diazepam 10mg previous night with tab Pantoprazole 20 mg at night. Midazolam 2mg was given IV before the field block. Patients were given field block with 1% lidocaine with adrenaline with a mean volume 35.48 ml, 15 ml of this solution was injected half an inch medial to anterior superior iliac spine, 5 ml at mid point of the inguinal ligament, and 5ml at pubic tubercle injected, about 10 ml injected subcutaneously. If the patients complain of discomfort during surgery 2 ml of lidocaine 1% was injected into neck of the hernial sac. Irrespective of discomfort during hernia repair, 25 mg of propofol was given as a sedative at the time of hernia repair. In patient where discomfort was present in addition to local anaesthetic at neck of the hernial sac 5 to 10 mg propofol additional dose given IV. If patient complains of pain in addition to above measures then Fentanyl 1 2 g/kg IV was administered. The following observations were made from the present study. Total study population Mean age 50

39.36 (18-60) years.

70

Sex M/F

50/0 60.74 kg (51-85 kg). I and II. 39.54 (28-60) min.

Mean weight

ASA physical status Mean surgery time Volume of the drug : Volume

35.48 (35-37) ml. Direct/Indirect 16/34.

Type of hernia

Quality of analgesia and relaxation : 1) Excellent 2) Good 3) Fair 4) Poor Success rate 8 4 96% Nil 16 72 96%

Intraoperative complications

72% of patients had excellent quality of analgesia and relaxation. 16% patients had good quality analgesia and relaxation, mild discomfort while handling sac. 8% of patients had fair quality of analgesia and relaxation only. In 4% patients the field block failed, in whom general anaesthesia was given. Overall success rate was 96%. Complications were nil. Then after the surgery, post anaesthesia recovery was assessed by using criteria for fast-track eligibility for ambulatory anaesthesia. The following observations were made from present study.

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TABLE 29 : FAST-TRACK ELIGIBILITY MEAN SCORE Parameters (MEAN SCORE) Physical activity Respiratory stability Haemodynamic stability Level of consciousness Oxygen saturation status Post-operative pain assessment Post-operative emetic symptoms Total score 0 2 2 2 1.96 2 2 1.96 13.92 Time (in minutes) 15 2 2 2 1.96 2 2 2 13.96 30 2 2 2 1.98 2 2 2 13.98

Our study correlates with studies conducted by Hangma et al.27 (2004), Ding Y et al.16 (1994), Kark AE et al.17 (1995), Song D et al.3 (2000), Apfelbaum JL et al.45+ (2002). From the present study it can be inferred that 1% lidocaine with adrenaline is effective for field block for inguinal hernia repair. Field block is safe anaesthesia with minimal physiological alterations, effective method for post-operative pain relief and helps in respect to speed of recovery. It is the method of choice for elective unilateral inguinal hernia repair.

72

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1) Kingsnorth, Bennett DH. Hernias, Umbillilus, Abdominal Wall Chapter 62. In : Short practice of surgery Bailey and Love. 23rd edn. 2000.p.1143. 2) Amid PK, Shulman AG. Local anaesthesia for inguinal hernia repair step by step procedure. Ann Surg 1994;220(6):735-737. 3) Song D, Greilich NB, White PF, Watcha MF, Tongier WK. Recovery profiles and costs of anaesthesia for out patient unilateral inguinal herniorrhaphy. Anaesth Analg 2000;91:876-81. 4) Flangan L, Bascom JU. Repair of the groin hernia out patient approach with local anaesthesia. Surg Clin North Am 1984;64(2):257-267. 5) Trice ET. The application of the principles of early ambulation to surgical patients. Virginia Medical Monthly 1947;74:103-107. 6) Iles T. The management of elective hernia repair. Ann Plast Surg 1979;2:538-542. 7) Prevoznik. Useful blocks in out patient anaesthesia in international

anaesthesiology. Clinic Kurt F. Schmidt 4 edn, 1976;2:91-95. 8) Teasdale C, McCrum A, Williams NB, Hortion RE. Randomized controlled trial to compare local with general anaesthesia for short-stay inguinal hernia repair. Ann R Coll Surg Engl 1982;64:238-242. 9) Glaslow F. Inguinal hernia repair using local anaesthesia. Ann R Coll Surg Engl 1984;66:382-387. 10) Young DV. Comparison of local, spinal and general anaesthesia for inguinal herniorrhaphy. Am J Surg 1987;153:560-563. 11) Reid MF, Harris R, Barker I, Pereira NH, Bennett NR. Day case herniotomy in children, a comparison of ilio-inguinal nerve block and wound infiltration for post operative analgesia. Anaesthesiology 1987;42:658-661.

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12) Hinkle AJ. Percutaneous inguinal block for the out patient management of post herniorrhaphy pain in children. Anaesthesiology 1987;67:411-413. 13) Tverjkoy M, Cozacovc, Ayache M, Bradley EL, Kissin I. Post operative pain after inguinal herniuorrhaphy with different type of anaesthesia. Anesth Analg 1990;70:29-35. 14) Cowdin HP, Triebwasser AS. Anaesthetic consideration in abdominal wall hernia. Chapter 44, Nyhus and Condons Hernia, 5th edn, 2001:p.518-519. 15) Dierking GW, Dahl JB, Kastrup J, Dahl A, Kehlet H. Effect of pre-vs post operative inguinal field block on postoperative pain after herniorrhaphy. Br J Anaesth 1992;68:344-348. 16) Ding Y, White PF. Post-Herniorrhaphy pain in outpatients after pre-incision ilioinguinal hypogastric nerve block during monitored anaesthesia care. Can J Anaesth 1995;42(1):12-15. 17) Kark AE, Kurzer M, Waters KJ. Tension free mesh hernia repair : Review of 1098 cases using local anaesthesia in a day unit. Ann R Coll Surg Engl 1995;77:299304. 18) Callesen T, Kehlet H. Post herniorrhaphy pain. Anaesthesiol 1997;87:1219-1230. 19) Callesen T, Beck K, Kehlet H. The feasibility, safety and cost of infiltration anaesthesia for hernia repair. Anaesthesiology 1998;53:31-35. 20) Marshall SI, Chung F. Discharge criteria and complication after ambulatory surgery. Anaesth Analg 1999;88:508-517. 21) Cousing, Bridenbough. Neural blockade in clinical anaesthesia and management of pain, 3rd edn, Lippincott raven. Philadelphia; 1998.

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22) Gianetta E, Cuneo S, Vitale B, Camerini G, Marini P, Stella M. Anterior tensionfree repair of recurrent inguinal hernia under local anaesthesia. Ann Surg 1999;231(1):132-136. 23) White PF. The role of non-opiod analgesic techniques in the management of pain after ambulatory surgery. Anaesth Analg 2002;94:577-585. 24) Aasbo V, Thuen A, Raeder J. Improved longlasting postoperative analgesia, recovery function and patient satisfaction after inguinal hernia repair with inguinal field block compared with general anaesthesia. Acta Anaesthsiologica Scandinaica 2002;46(6):674-678. 25) Pregler JL, Kapur PA. The development of ambulatory anaesthesia and future challenges. Anaesthesiol Clin North Am 2003;21:207-228. 26) Sinnot JC, Cogswell LP, Johnson A, Sirichartz GR. On the mechanism by which epinephrine potentiates lidocaines peripheral nerve block. Anaesthesiology 2003;98:181-188. 27) Ma H, Tang J, White PF, Zaentz A, Wender RH, Sloninsky A et al. Perioperative rofecoxib improves early recovery after outpatient herniorrhaphy. Anaesth Analg 2004;98:970-975. 28) Willschke H, Marhofer P, Bosenberg A, Johnston S, Wanzel O, Cox SG et al. Ultrasonography for ilioinguina/iliohypogastric nerve blocks in children. Br J Anaesth 2005;95(2(:226-230. 29) Cleres, Vuilleumier H, Frascorolop, Spahn DR, Gardaz JP. Is the effect of inguinal field block with 0.5% bupivacaine on postoperative pain after hernia repair enhanced by addition of keterolac or S (+) Ketamine ? Clin J Pain 2005;21(1):101-105.

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30) Anderson FH, Nielson K, Kehlet H. Combined illioinguinal blockade and local infiltration anaesthesia for groin hernia repair a double blind randomized study. Br J Anaesth 2005;94:520-523. 31) Atkinson RS, Rushman GB, Lee JA. Section 4 regional techniques. In: Lees synopsis of anaesthesia. 11th edn. 1993:p. 666. 32) Singh I. The abdomin and pelvis. Chapter 39. In : Text book of anatomy with colour atlas. Vol. 2. 2nd edn. 1999: p. 597-602. 33) Snell RS. The abdomen : Part I. The abdominal wall. Chapter 4. In : Clinical anatomy. 4th edn. 2004:p.172-174. 34) Healy CJ, Borley NR. Posterior abdominal wall and retroperitoneum, Section 7 : Abdomen and pelvis. Chapter 68. In : The anatomical basis of clinical practise, Grays Anatomy. 39th edn. 2005:p. 1124-1126. 35) Stoelting RK, Hetlies C, Simon. Local anaesthetics, Chapter 7. In : Pharmacology : pharmacology and physiology in anesthetic practice. 4th edn. 2006:p.179-180. 36) Miller RD. Millers Anaesthesia, JG Reves, Peter SA Glass, David A Lubarsky and Mathew D. McEvoy (edt), 6th ed. Elsevier Churchill Living Stone. USA, 2005;1:345-350, 28-30pp. 37) Collins VJ. Local anaesthetis, Section II : Regional anesthesia. Chapter 42. In : Principles of anaesthesiology, general and regional anaesthesia. 3rd edn. 1993:p.1232-33,1257-59. 38) Dexter F, Macario A, Penning DH, Chung P. Development of an appropriate list of surgical procedures of a specified maximum anaesthetic complexity to be performed at a new ambulatory surgery facility. Anaesth Analg 2002;95:78-82. 39) Ansell GL, Montgomery JE. Out come of ASA III patients undergoing day case surgery. Br J Anaesth 2004;92(1):71-74.

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40) Earle AS. Local anaesthesia for inguinal herniorrhaphy. Am J Surg 1960;100:782786. 41) Dunn J, Day CJE. Local anaesthesia for inguinal and femoral hernia repair update in anaesthesia for Inguinal and Femoral Hernia Repair. 1994;4Article 6:1-2. 42) Zoilinger RM, Konstantakos AK, Stellato TA, Hirgchfeld SS. Local anaesthesia plus deep sedation for adult inguinal hernia repair in an ambulatory surgery. Springlink-Journal article, Hernia 1998;2(2):77-80. 43) Covino, Benjamin G, Heleng, Vasalio. Clinical aspect of Local anaesthesia. Chapter 4, Local anaesthetic mechanism of action and clinical use. Published by Grane and Stralioninc New York 1976:58-59 44) Paul WF, Song, Dajun. New criteria for fast tracking after out patient anaesthesia. A comparison with modified aldrets scoring system. Anaesth Analg 1999;88:1069-72. 45) Apfubaum JL, Walawander CA, Grasela TH, Wise PBS, McLeskey C, Roizen MF et al. Eliminating intensive postoperative care in same-day surgery patients using short-acting anaesthetics. Anaesthesiology 2002;97:66-74. 46) Prado E, Herrera MF, Letay FV. Inguinal herniorrhaphy under local anesthesia : a study of introperative tolerance. Am Surg 1994;60(8):617-619. 47) Brown DL. Inguinal block. Chapter 36 Atlas of regional anaesthesia, 2nd edn. 1992:263-266.

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Annexures

ANNEXURE I
FIELD BLOCK FOR INGUINAL HERNIA REPAIR A CLINICAL STUDY

PROFORMA
Name of the patient : Age : Sex : Weight : Address :

I.P. No. : Date of admission : History of present complaints :

Co Existing disease : Past history :

Personal history :

General examination : Built poor / Moderate / Good / Obese Pallor, Icterus, Clubbing, Kylonychia, Lymphadenopathy, Edema. Vital signs : PR. BP.

Airway assessment : Mallampatti grading :

78

Local examination : Type of hernia (direct / indirect) Side (right/left)

Systemic examination : CVS : RS : Spine : Abdomen : Investigation : Blood : Urine : Blood urea Chest x-ray : Hb% Alb BT Sugar Serum creatinine ECG : CT TC DC

Microscopy RBS

ASA grading (ASA I / ASA II) : Premedication : Field block drug used percentage of drug used

Volume of drug used Site 1. an inch medial to ASIS 2. 0.5 cm above mid point of the inguinal ligament 3. At a point medial to pubic tubercle 4. Subcutaneous infiltration 5. Neck of sac of hernia Volume in ml

79

Quality of analgesia and relaxation : Excellent Good Fair Poor

Intra-operative complications : Additional methods : Monitoring : Time (min) PR BP SPO2 Duration of surgery : Recovery scale : Criteria used to determined fast track eligibility after ambulatory anaesthesia : Time 0 min 15 min 30 min Physical activity Respiratory stability Haemodynamic stability Level of consciousness Oxygen saturation status Post operative pain assessment Post operative emetic symptoms Total duration of analgesia : From institution of block to time of requirement of oral or parentral analgesics. Post operative complications : 0 5 10 15 20 30 45

80

ANNEXURE II CONSENT FORM FOR ANAESTHESIA/OPERATION

I ..Hosp. No..in my full senses hereby give my complete consent for ..or any other procedure deemed fit which is a / and diagnostic procedure / biopsy / transfusion / operation to a be performed on me / my son / my daughter / my ward age under any anaesthesia deemed fit. The nature and risk involved in the procedures have been explained to me to my satisfaction. For academic and scientific purpose the operation / procedure may be televised or photographed.

Date: Signature / Thumb Impression of the Patient / Guardian Name: Place: Guardian Relationship Full Address

81

MASTER CHART
A7 35 35 35 35 35 35 35 37 35 35 35 37 37 35 37 35 35 35 35 35 37 35 35 35 37 35 35 35 35 35 35 37 37 37 35 37 35 35 35 35 35 37 35 35 35 35 35 35 37 35 E E E G E E F E E E G E E E E G G E F E G E E E E E E G F E E E P E E G E E E G E E F E E E E E P E 84 108 123 84 86 84 90 84 80 74 80 90 84 86 90 82 76 90 84 84 84 88 82 87 74 86 88 84 78 80 88 84 78 98 72 76 70 76 84 88 88 94 74 90 84 60 80 60 64 64 89 96 104 96 96 90 90 90 100 94 99 78 123 75 96 92 88 100 84 80 80 86 91 86 76 110 90 90 90 90 78 90 100 88 78 90 100 94 90 90 80 80 100 80 70 90 76 78 86 70 86 83 80 106 90 90 84 84 84 94 84 84 84 127 80 100 84 82 85 90 76 84 84 88 90 100 75 90 78 76 84 84 76 86 92 84 84 84 84 82 82 84 84 84 96 90 68 92 80 58 74 91 101 92 88 88 86 82 92 86 88 76 117 85 100 86 90 76 97 78 88 76 90 97 8 72 100 76 74 82 86 74 84 90 82 86 80 82 86 84 86 100 86 90 95 64 88 80 70 84 72 84 99 88 84 86 84 84 94 82 84 80 110 75 90 82 80 84 93 76 86 80 84 94 84 79 86 80 78 86 82 73 86 84 84 86 84 84 88 82 82 96 90 90 80 72 84 80 69 82 70 88 91 84 88 88 82 86 96 84 82 78 180 75 90 84 78 82 91 74 92 80 84 86 80 80 92 84 76 84 84 76 84 88 82 78 86 86 80 74 84 80 84 86 80 60 80 78 90 84 72 82 90 80 86 80 80 80 90 80 80 74 106 70 82 88 72 84 93 72 96 84 84 80 80 84 82 74 78 80 86 74 80 82 80 84 82 88 84 86 82 80 86 96 95 70 82 76 86 86 70 78 90 84 84 84 84 84 92 84 86 78 96 75 92 84 76 86 99 78 94 88 88 84 80 84 80 82 76 84 84 72 88 86 86 82 84 82 86 82 84 84 80 90 95 70 80 73 84 84 S 130 110 137 140 110 110 120 150 120 106 120 100 120 120 140 130 110 122 109 110 190 120 110 132 106 120 120 120 130 150 112 124 120 110 150 150 150 110 130 130 160 130 110 120 108 110 120 120 140 120 D 88 60 98 80 70 70 80 82 80 54 80 60 80 70 70 80 70 80 80 70 90 78 70 71 60 70 80 80 90 90 80 90 80 80 90 90 100 70 80 90 100 90 70 80 50 60 70 80 80 80 D 71 84 90 80 80 80 80 70 80 90 70 80 84 80 69 86 80 74 72 80 82 88 80 74 80 80 90 80 80 90 80 80 70 90 80 90 90 90 80 80 90 90 80 90 90 70 90 80 90 90 D 70 65 66 72 76 76 76 76 76 76 70 84 70 86 71 84 85 58 69 76 78 76 80 90 90 64 80 76 76 86 76 76 90 86 70 80 80 76 86 86 76 86 80 80 90 70 80 80 60 80 D 69 60 59 82 70 70 70 70 70 70 70 84 73 70 73 80 80 68 59 70 70 88 80 74 80 66 90 70 74 82 74 74 80 82 70 78 70 74 88 82 76 90 70 80 80 70 70 80 70 80 D 55 59 67 92 68 69 78 68 68 70 68 60 80 68 69 78 78 70 54 68 80 80 80 86 76 75 80 72 70 84 72 72 92 84 82 72 80 72 80 84 80 80 80 80 80 80 90 80 80 80 D 69 58 85 84 74 74 74 74 74 74 73 60 81 74 69 84 80 86 56 72 80 80 70 76 90 78 70 80 70 70 70 78 82 76 82 78 82 82 74 84 82 70 57 70 70 80 80 80 80 70 A8 A9 A10 A11 A12 A13 A14 A15 A16 A17 A18 S 123 135 149 170 130 120 120 130 130 130 130 120 100 130 121 136 120 120 136 120 100 130 120 141 120 120 160 130 140 150 130 130 130 130 150 110 140 140 140 130 140 120 110 140 150 124 140 120 140 140 A19 S 118 120 116 130 116 116 116 116 116 116 136 130 148 126 128 133 130 122 129 116 102 126 116 140 130 115 140 126 116 126 116 116 140 113 130 130 120 126 120 126 116 126 130 130 140 110 120 130 120 120 A20 S 117 132 109 140 113 113 113 113 113 112 133 120 143 123 12 132 120 112 117 113 98 124 137 137 120 121 130 124 114 114 150 112 146 116 110 124 127 124 114 140 120 130 130 100 110 130 120 120 127 110 A21 S 104 129 95 130 111 111 111 111 111 111 131 100 142 122 124 131 118 132 112 112 120 122 120 137 116 129 140 122 112 124 112 112 120 120 130 110 120 122 124 122 120 110 130 120 120 120 120 110 110 120 A22 S 104 119 112 130 111 111 111 111 112 112 135 100 143 122 132 136 120 155 111 114 120 120 110 143 110 121 160 124 110 120 114 112 100 112 130 113 122 122 127 124 114 122 121 110 126 110 110 120 120 120 A23 S 110 116 95 130 110 110 112 116 110 110 141 120 140 122 133 132 125 154 116 110 120 120 120 130 112 128 120 120 112 120 112 110 120 110 120 114 110 124 122 110 112 125 122 120 110 100 120 120 120 120 D 60 56 59 80 70 73 74 70 70 70 70 80 80 97 76 82 78 88 50 70 80 84 80 70 72 76 80 70 72 80 70 70 90 70 70 72 84 76 84 84 72 83 84 80 70 60 80 80 80 90 A24 S 110 110 110 140 112 115 115 112 115 115 135 120 143 124 130 133 110 150 131 112 120 120 120 130 120 120 120 122 112 110 110 120 112 130 116 110 124 110 122 110 126 110 120 110 120 120 120 120 120 120 D 62 58 70 90 74 73 74 74 73 73 74 80 81 74 80 84 70 90 72 74 80 82 80 80 86 70 80 72 72 80 70 70 70 82 80 74 70 82 82 84 70 82 84 80 70 80 80 80 80 80

A0

A1

A2

A3

A4

A5

A6

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

29466 29367 0072 29697 02290 02392 02826 3335 3880 3986 4547 4558 4550 15318 4198 15626 16143 16257 17861 18666 21409 21369 23157 23171 23866 24259 25005 25970 26932 26540 26671 27145 27125 12922 27609 28028 28658 27118 29421 29677 29427 29679 29684 29690 21230 22460 23390 23492 24550 29578

27 19 20 21 22 23 24 23 24 22 26 27 28 29 30 29 31 32 33 34 35 36 37 39 38 40 38 41 43 42 44 47 49 51 52 54 53 55 53 56 56 57 58 59 59 56 54 49 45 48

M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M

51 52 54 52 53 56 57 59 60 56 57 55 54 58 57 52 55 51 56 54 58 54 55 59 55 54 61 62 64 65 67 65 62 62 65 68 69 70 65 62 63 64 69 69 63 74 77 85 68 64

LD LI RI RD LD RI RD RI RD RI RI RD LI RD RI LI LI RI RI RI LI LI LI LI RI RI RI RI RI RI RI RI LI LI RD LI LD RI LD LD RD LD RI RD LD LD RI RI RI RI

M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-30 M-2P-25 M-2P-25 M-2P-25 M-2P-30 FE-80 M-2P-30 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 FE-90 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-30 M-2P-30 M-2P-30 FE-80 M-2P-25 FE-100 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 FE-90 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 M-2P-25 FE-100 M-2P-25 M-2P-25

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A25 99 98 99 97 98 99 98 97 98 99 99 99 99 99 99 99 99 99 98 99 98 99 98 96 97 99 99 98 98 98 98 98 98 98 98 98 99 99 99 98 99 98 99 99 99 99 99 99 99 99

A26 99 99 99 98 97 97 98 98 98 97 98 96 97 98 99 98 98 98 98 97 98 98 98 97 99 99 98 99 99 98 99 98 98 98 99 98 98 98 98 98 99 98 99 99 98 99 99 98 99 99

A27 99 98 99 97 98 99 98 97 98 99 99 99 99 99 99 99 99 99 98 99 98 99 98 96 97 99 99 98 98 98 98 98 98 98 98 98 99 99 99 98 99 98 99 99 99 99 99 99 99 98

A28 99 99 99 98 97 97 98 98 98 97 98 96 97 98 99 98 98 98 98 97 98 98 98 97 99 99 98 99 99 98 99 98 98 98 99 98 98 98 98 98 99 98 99 99 98 99 99 98 99 97

A29 99 98 99 97 98 99 98 97 98 99 99 99 99 99 99 99 99 99 98 99 98 99 98 96 97 99 99 98 98 98 98 98 98 98 98 98 99 99 99 98 99 98 99 99 99 99 99 99 99 96

A30 99 99 99 98 97 97 98 98 98 97 98 96 97 98 99 98 98 98 98 97 98 98 98 97 99 99 98 99 99 98 99 98 98 98 99 98 98 97 98 98 99 98 99 99 98 99 99 98 99 99

A31 99 98 99 97 98 99 98 97 98 99 99 99 99 99 99 99 99 99 98 99 98 99 98 96 97 99 99 98 98 98 98 98 98 98 98 98 99 99 99 98 96 98 99 99 99 99 99 99 99 99

A32 99 99 99 98 97 97 98 98 98 97 98 96 97 98 99 98 98 98 98 96 98 98 98 97 99 99 98 99 99 98 99 98 98 98 99 98 98 98 98 98 99 98 99 99 98 99 99 98 99 99

A33 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL

A34 NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL

A35 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A36 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A37 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A38 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A39 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A40 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A41 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A42 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A43 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A44 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2

A45 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2

A46 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2

A47 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A48 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A49 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A50 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A51 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A52 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A53 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2

A54 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A55 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

A56 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 12 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 12 14

A57 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 13 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 13 14

A58 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 13 14

A59 210 180 275 280 210 240 250 230 220 210 240 220 210 220 210 220 210 220 210 220 210 200 195 180 210 160 170 165 160 170 180 210 160 200 210 200 190 180 170 190 195 192 172 165 162 160 210 220 160 220

A60 40 42 40 48 39 31 35 46 35 30 36 44 35 31 60 31 44 39 32 33 45 32 46 33 60 34 28 32 45 33 31 60 45 30 30 45 38 36 45 34 44 60 35 43 47 39 32 46 38 40

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KEY TO MASTER CHART

A A1 A2 A3 A4 A5 A6 Serial number Code No / I.P. No. Age Sex Weight Type of hernia : Direct D : Indirect ID : R Right : L Left Premedication Midazolam 2mg M-2 Propofol 25 mg P- 25 Fentanyle 1-2 g/ kg A7 A8 Volume of Lidocaine Quality of block (Analgesia) E- Excellent; G- Good ; F- Fair; P- Poor. Heart Rate A9 A10 A11 A12 A13 A14 A15 A16 at pre-operative at 0 minute (immediately after block) at 5 min at 10 min at 15 min at 20 min at 30 min at 45 min

Blood Pressure : A17 A18 A19 A20 A21 A22 A23 A24 at pre operative at 0 min at 5 min at 10 min at 15 min at 20 min at 30 min at 45 min

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Saturation of oxygen : A25 A26 A27 A28 A29 A30 A31 A32 A33 A34 at pre-operative at 0 min at 5 min at 10 min at 15 min at 20 min at 30 min at 45 min complications Additional methods

Recovery Scale : Criteria used to determine fast-track eligibility after ambulatory anaesthesia.

Physical Activity : (After the surgery) A35 A36 A37 at 0 min at 15 min at 30 min

Respiratory stability : (After the surgery) A38 A39 A40 at 0 min at 15 min at 30 min

Haemodynamic stability : (After the surgery) A41 A42 A43 at 0 min at 15 min at 30 min

Levels of consciousness : (After the surgery) A44 A45 A46 at 0 min at 15 min at 30 min

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Oxygen saturation status : (After the surgery) A47 A48 A49 at 0 min at 15 min at 30 min

Postoperative pain assessment : (After the surgery) A50 A51 A52 A53 A54 A55 at 0 min at 15 min at 30 min

Postoperative emetic symptoms : (After the surgery) at 0 min at 15 min at 30 min

Total score : (After the surgery) A56 A57 A58 A59 A60 at 0 min at 15 min at 30 min Duration of analgesia (in min) Duration of surgery (in min)

86