BOB Ped Surg 2023 - Wendy Song, CAPS - Presentation

Hey everyone, my name is Wendy. Today I'll be presenting on my project a comparison of operative and anesthetic techniques for inguinal hernia repair in infants on behalf of the Canadian Association of Pediatric surgeons. I have no financial disclosures to make. So inguinal hernia repairs are some of the most common pediatric surgical procedures and are traditionally performed under general anesthesia for open surgery. However, many centers have recently started utilizing the minimally invasive approach with regional anesthesia instead. Over the last five years at BC Children's Hospital, a tertiary care teaching center, surgeons and anesthesiologists have utilized four different combinations of surgical and anesthetic techniques, including general anesthesia with open surgery, GO, caudal anesthesia with open surgery CO, general anesthesia with laparoscopy GL, and caudal anesthesia with laparoscopy CL. So CL is a newer combination that was recently adopted and its safety was demonstrated in a prior case study. The primary objective therefore was to evaluate the surgical outcomes and resource utilization of pediatric inguinal hernia repairs between the different surgical and anesthetic combinations against the newer CL technique, which has previously not been described in literature. So we've conducted a retrospective cohort study including all infants less than one years old undergoing an elective inguinal hernia repair from July of 2016 to 2021 at a single tertiary care teaching center. We've excluded all inguinal hernia repairs with concomitant procedures and emergent procedures from strangulated or incarcerated hernias. In total, eight surgeons and 25 anesthesiologists contributed patients with approach dictated by practitioner preference. So here you can see there was 465 infants that were initially assessed for eligibility of which only 338 patients uh were included in the final study analysis. So most patients underwent an open procedure and only 63 cases were laparoscopic. There was a relatively even split between caudal anesthesia and general anesthesia as well. Of the 338 patients that were included, most were pre-term males and uh were followed for a median of 2.5 years. There were two crossovers that occurred in the analysis, one conversion in the GL group to open surgery as the patient was unable to tolerate the pneumoperitoneum. Another case required conversion to general anesthesia in the caudal group because the patient did not tolerate the incision despite initially passing the pinch test. Since the primary objective was surgical complications, we saw that there was no statistical difference found between groups for the aggregate post-operative complication rates, including recurrence. Metachronous hernias also occurred at a similar rate for open and laparoscopic approaches, albeit with a modest follow-up irrespective of anesthetic choice. Secondary outcomes included uh OR utilization. So we saw the total OR time was significantly different between groups with caudal caudal anesthesia with open surgery being the shortest. It was significantly shorter than caudal anesthesia with laparoscopy by 15 minutes and general anesthesia with open surgery by 9 minutes. In terms of anesthetic preparation time or skin to skin time, there was no difference between the groups, but the overall post procedure time was significantly shorter in patients receiving a caudal blockade than general anesthesia, with four minutes saved in the laparoscopic group and eight minutes in the open group. To conclude, the use of laparoscopy with caudal anesthesia CL appears to be a safe and effective option in terms of post-operative complications compared to other groups. There was also a similar rate of aggregate complications including recurrence and metachronous hernia between the groups. Secondly, caudal anesthesia with open surgery had a significantly shorter total OR time compared to other groups and appeared to be the most resource efficient inguinal hernia repair method. Finally, caudal anesthesia has significantly shorter post procedure times compared to GA. Finally, our study does have several limitations. Firstly, due to the retrospective nature of the project, it is subject to the normal bias of any retrospective review. Furthermore, due to lack of cross hospital EMRs, the study follow-up was unable to capture post-operative complications managed at any other hospital or clinic. Finally, the next steps for this project would be to explore a larger or prospective study or even a planetary analysis looking at the impact of the different surgical and anesthetic combinations. Thank you for your attention.