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BOB Ped Surg 2023 - Wendy Song, CAPS - Presentation

Video Published 2023-02-06 Updated 2026-08-01

Timestops (7)

Introduction of the project

Introduction of the project: Comparing operative and anesthetic techniques for inguinal hernia repair in infants.

Background on inguinal hernia repairs and the shift towards …

Background on inguinal hernia repairs and the shift towards minimally invasive approaches.

Primary objective

Primary objective: Evaluating surgical outcomes and resource utilization compared to the CL technique.

Study design: Retrospective cohort study details.

Patient selection and study population numbers.

Results: No significant difference in post-operative complication rates.

Results: OR utilization and post procedure times.

Topic Overview

A retrospective cohort study comparing four combinations of surgical and anesthetic techniques for elective inguinal hernia repair in infants under one year at BC Children's Hospital from 2016-2021. The study included 338 patients across general anesthesia with open surgery (GO), caudal anesthesia with open surgery (CO), general anesthesia with laparoscopy (GL), and caudal anesthesia with laparoscopy (CL). No significant differences in post-operative complication rates, recurrence, or metachronous hernias were found between groups. Caudal anesthesia with open surgery demonstrated the shortest total OR time, while caudal anesthesia showed significantly shorter post-procedure times compared to general anesthesia regardless of surgical approach.

Key Takeaways

Caudal anesthesia with open surgery achieved shortest total OR time, 15min faster than caudal+laparoscopy, 9min faster than GA+open. (8:30)
No significant difference in post-op complications, recurrence, or metachronous hernias across all four technique combinations (n=338). (7:30)
Caudal blockade reduced post-procedure time by 4-8 minutes vs general anesthesia regardless of surgical approach (open or laparoscopic). (10:30)
Laparoscopy with caudal anesthesia is safe and effective for infant inguinal hernia repair, with comparable complication rates to other methods. (2:00)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Wendy — guest

Chapters

0:00Introduction and Background — Introduction of presenter and project overview. Background on traditional versus minimally invasive approaches to pediatric inguinal hernia repair and the four technique combinations used at BC Children's Hospital.
2:00Study Methodology — Description of retrospective cohort study design, inclusion and exclusion criteria, patient population, and study period from July 2016 to 2021.
3:00Results: Complications and Outcomes — Presentation of primary outcome data showing no statistical difference in post-operative complication rates, recurrence, or metachronous hernias between groups.
4:00Results: OR Utilization — Secondary outcome data on operating room time utilization, showing caudal anesthesia with open surgery had shortest total OR time and caudal anesthesia had shorter post-procedure times.
5:00Conclusions and Limitations — Summary of key findings, study limitations including retrospective design and follow-up constraints, and proposed next steps for future research.

Key claims

0:00Inguinal hernia repairs are some of the most common pediatric surgical procedures and are traditionally performed under general anesthesia for open surgery — Wendy
1:00Many centers have recently started utilizing the minimally invasive approach with regional anesthesia instead of traditional general anesthesia with open surgery — Wendy
1:30Over the last five years at BC Children's Hospital, surgeons and anesthesiologists have utilized four different combinations of surgical and anesthetic techniques — Wendy
2:00The safety of caudal anesthesia with laparoscopy (CL) was demonstrated in a prior case study — Wendy
2:30The CL technique has previously not been described in literature for comparison with other approaches — Wendy
3:00The study included all infants less than one year old undergoing elective inguinal hernia repair from July 2016 to 2021 at a single tertiary care teaching center — Wendy
3:30Inguinal hernia repairs with concomitant procedures and emergent procedures from strangulated or incarcerated hernias were excluded from the study — Wendy
4:00Eight surgeons and 25 anesthesiologists contributed patients with approach dictated by practitioner preference — Wendy
4:30465 infants were initially assessed for eligibility of which 338 patients were included in the final study analysis — Wendy
5:00Most patients underwent an open procedure with only 63 cases being laparoscopic — Wendy
5:30There was a relatively even split between caudal anesthesia and general anesthesia — Wendy
6:00Most included patients were pre-term males and were followed for a median of 2.5 years — Wendy
6:30There were two crossovers: one conversion in the GL group to open surgery because the patient was unable to tolerate the pneumoperitoneum — Wendy
7:00One case required conversion to general anesthesia in the caudal group because the patient did not tolerate the incision despite initially passing the pinch test — Wendy
7:30There was no statistical difference found between groups for the aggregate post-operative complication rates, including recurrence — Wendy
8:00Metachronous hernias occurred at a similar rate for open and laparoscopic approaches, albeit with a modest follow-up irrespective of anesthetic choice — Wendy
8:30Total OR time was significantly different between groups with caudal anesthesia with open surgery being the shortest — Wendy
9:00Caudal anesthesia with open surgery was significantly shorter than caudal anesthesia with laparoscopy by 15 minutes — Wendy
9:30Caudal anesthesia with open surgery was significantly shorter than general anesthesia with open surgery by 9 minutes — Wendy
10:00There was no difference in anesthetic preparation time or skin to skin time between the groups — Wendy
10:30Overall post procedure time was significantly shorter in patients receiving a caudal blockade than general anesthesia, with four minutes saved in the laparoscopic group — Wendy
11:00Overall post procedure time was significantly shorter in patients receiving a caudal blockade than general anesthesia, with eight minutes saved in the open group — Wendy
11:30The use of laparoscopy with caudal anesthesia appears to be a safe and effective option in terms of post-operative complications compared to other groups — Wendy
12:00Caudal anesthesia with open surgery appeared to be the most resource efficient inguinal hernia repair method — Wendy
12:30Due to the retrospective nature of the project, it is subject to the normal bias of any retrospective review — Wendy
13:00Due to lack of cross hospital EMRs, the study follow-up was unable to capture post-operative complications managed at any other hospital or clinic — Wendy

Open questions

What would a larger prospective study or planetary analysis reveal about the impact of different surgical and anesthetic combinations?
How many post-operative complications were missed due to lack of cross-hospital EMR access?
What is the optimal follow-up duration to adequately capture metachronous hernia rates?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Caudal Anesthesia for Pediatric Inguinal Hernia Repair: Safety and Efficiency Data

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why Regional Anesthesia Matters in Infant Surgery

Inguinal hernia repair is one of the highest-volume procedures in pediatric surgery, traditionally performed open under general anesthesia 0:30. The shift toward regional anesthesia—specifically caudal blockade—emerged from a practical question: could you avoid intubating an infant for a groin incision? The appeal is straightforward: faster recovery, less airway manipulation, potentially shorter OR time. Laparoscopy entered the conversation separately, driven by the promise of contralateral visualization and reduced recurrence. What had not been systematically compared was the full matrix: open versus laparoscopic, general versus caudal, and the four combinations those variables create 1:30.

This study from BC Children's Hospital examined 338 infants under one year old across five years, comparing general anesthesia with open repair (GO), caudal with open (CO), general with laparoscopy (GL), and caudal with laparoscopy (CL) 3:00. The CL combination—caudal blockade for a laparoscopic case—had been described in a prior safety report but never compared head-to-head with the other approaches 2:00 2:30. Multiple surgeons and anesthesiologists contributed cases, with technique choice driven by individual preference rather than protocol 4:00.

The Core Question: Safety and Resource Use

The primary outcome was surgical complications, including recurrence and metachronous contralateral hernias. The secondary outcome was OR efficiency: total room time, anesthetic prep, skin-to-skin operative time, and post-procedure turnover 1:30.

Most patients in this cohort were preterm males, followed for a median 2.5 years 6:00. The distribution skewed heavily toward open repair, with a roughly even split between caudal and general anesthesia 5:00 5:30. Two crossovers occurred: one laparoscopic case converted to open when the infant could not tolerate pneumoperitoneum, and one caudal case required conversion to general anesthesia when the patient did not tolerate incision despite passing the pinch test 6:30 7:00.

What the Data Showed

Complication rates were statistically indistinguishable across all four groups 7:30. Recurrence occurred at similar rates regardless of surgical or anesthetic approach. Metachronous hernias—contralateral hernias appearing later—also occurred at comparable rates between open and laparoscopic techniques, though the authors noted the follow-up period was modest 8:00. The CL combination, which had raised theoretical concerns about maintaining adequate anesthesia during insufflation, proved as safe as the traditional GO approach in this cohort 11:30.

The efficiency picture was more differentiated. Total OR time was shortest for caudal with open repair (CO), which beat caudal with laparoscopy by 15 minutes and general with open by 9 minutes 8:30 9:00 9:30. Anesthetic preparation time and skin-to-skin operative time did not differ between groups, meaning the time savings came from post-procedure recovery 10:00. Caudal blockade consistently shortened post-procedure time compared to general anesthesia—by several minutes in both laparoscopic and open cases 10:30 11:00. The presenter concluded that CO appeared to be the most resource-efficient method overall 12:00.

Where Uncertainty Remains

This was a retrospective review at a single center with technique choice determined by practitioner preference, not randomization 12:30. The lack of cross-hospital electronic records meant that complications managed elsewhere went uncaptured 13:00. The laparoscopic cohort was smaller than the open cohort, which limits the power to detect rare events. The follow-up period, while adequate for early recurrence, may not capture late metachronous hernias that present beyond 2.5 years.

The study does not address patient selection. It is unclear whether infants receiving caudal anesthesia were systematically different—healthier, older, less premature—than those receiving general anesthesia. The two crossovers hint at the limits of caudal blockade: one infant could not tolerate the incision despite adequate testing, and another could not tolerate laparoscopic insufflation 6:30 7:00. These are not technique failures; they are reminders that infant physiology is variable and that backup plans matter.

When to Consider Caudal Blockade

For a referring clinician or a surgeon considering technique options, the takeaway is that caudal anesthesia appears safe for both open and laparoscopic inguinal hernia repair in infants, with a measurable efficiency advantage in post-procedure time 11:30. The CO combination—caudal with open repair—was the fastest overall approach in this cohort 12:00. Whether that efficiency translates to meaningful throughput gains depends on your OR's bottlenecks: if turnover is the constraint, saving several minutes per case matters; if block time is fixed and underutilized, it does not.

The study does not provide referral criteria or contraindications for caudal anesthesia, nor does it specify which infants were deemed unsuitable for regional blockade. Those decisions remain institution-specific and anesthesiologist-dependent. What this study does offer is reassurance that the CL combination—previously undescribed in comparative literature—does not carry excess risk and that caudal blockade, when feasible, shortens recovery without compromising outcomes 2:30 11:30.

Takeaways from this story

Caudal anesthesia with laparoscopy showed equivalent complication rates to traditional general anesthesia approaches in infants.
Caudal blockade shortened post-procedure time compared to general anesthesia regardless of surgical technique.
Open repair with caudal anesthesia was the fastest overall approach, beating caudal-laparoscopy by 15 minutes and general-open by 9 minutes.
Metachronous hernia rates were similar between open and laparoscopic approaches at median 2.5-year follow-up.

Caudal Anesthesia for Pediatric Inguinal Hernia Repair: Safety and Efficiency Data

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Explainer · AI-written, human-reviewed

Why This Matters

Inguinal hernia repair is one of the most common pediatric surgical procedures 0:00. For decades, the standard approach combined open surgery with general anesthesia. Over the past five years, pediatric centers have begun mixing and matching surgical technique (open versus laparoscopic) with anesthetic approach (general versus regional), creating four distinct combinations 1:00 1:30. The question for referring clinicians and surgical colleagues is whether these newer combinations—particularly caudal anesthesia with laparoscopy—are safe and whether they offer meaningful advantages in operating room efficiency.

The Clinical Problem

The traditional approach works, but general anesthesia carries its own risks in infants, particularly those born prematurely. Regional anesthesia with a caudal block offers an alternative that avoids airway instrumentation and may speed recovery. Laparoscopy allows contralateral exploration and repair through smaller incisions but requires pneumoperitoneum, which some infants tolerate poorly. The question is whether combining these techniques—especially the novel pairing of caudal anesthesia with laparoscopy—compromises safety or offers efficiency gains worth adopting.

How the Study Worked

A single tertiary care center in British Columbia tracked 338 infants under one year old who underwent elective inguinal hernia repair between 2016 and 2021 3:00. Multiple surgeons and anesthesiologists contributed cases, with technique choice driven by practitioner preference rather than protocol 4:00. The four combinations studied were general anesthesia with open surgery (GO), caudal anesthesia with open surgery (CO), general anesthesia with laparoscopy (GL), and caudal anesthesia with laparoscopy (CL). Most patients were preterm males, and median follow-up was 2.5 years 6:00.

The distribution was heavily weighted toward open surgery—only 63 of 338 cases were laparoscopic—but anesthetic choice was roughly split between general and caudal 5:00 5:30. Emergency cases and repairs done alongside other procedures were excluded 3:30.

Two crossovers occurred: one laparoscopic case converted to open when the infant could not tolerate pneumoperitoneum, and one caudal case required conversion to general anesthesia when the patient did not tolerate incision despite passing the pinch test 6:30 7:00. These failures are instructive—they represent the real-world limits of each technique.

What They Found

The primary outcome was safety, measured by postoperative complications including recurrence. No statistical difference emerged between the four groups 7:30. Metachronous hernias—contralateral hernias appearing later—occurred at similar rates for open and laparoscopic approaches, regardless of anesthetic choice, though the follow-up period was modest 8:00. The conclusion: caudal anesthesia with laparoscopy appears as safe as the traditional approach in terms of postoperative complications 11:30.

The secondary outcome was operating room efficiency, broken into anesthetic preparation time, skin-to-skin surgical time, and post-procedure time. Total OR time was shortest for caudal anesthesia with open surgery (CO)—15 minutes shorter than caudal with laparoscopy and 9 minutes shorter than general with open surgery 8:30 9:00 9:30. Anesthetic preparation and surgical time did not differ between groups 10:00, meaning the efficiency gain came entirely from post-procedure time. Caudal anesthesia shortened post-procedure time compared to general anesthesia in both laparoscopic and open cases 10:30 11:00. The presenter concluded that caudal anesthesia with open surgery was the most resource-efficient method 12:00.

Where Uncertainty Remains

This is retrospective data from a single center with technique choice determined by individual preference, not randomization 12:30. The study could not capture complications managed at outside hospitals or clinics due to lack of cross-institutional electronic records 13:00. The laparoscopic cohort was small—63 cases versus the larger open cohort—which limits the power to detect rare complications. Follow-up was 2.5 years, which may miss late recurrences or metachronous hernias that declare themselves later.

The study does not address which patients are best suited for caudal anesthesia or which anatomic features predict failure. The two crossovers suggest that some infants will not tolerate regional anesthesia or pneumoperitoneum, but the study offers no preoperative criteria to identify them.

When to Refer

This study does not change referral indications—any infant with an inguinal hernia should be referred to pediatric surgery for elective repair. What it does suggest is that caudal anesthesia is a reasonable option for infants undergoing hernia repair, particularly if OR efficiency is a concern. The choice between open and laparoscopic technique, and between general and regional anesthesia, remains a conversation between surgeon, anesthesiologist, and family, informed by the infant's comorbidities and the team's experience. The data here support that conversation by demonstrating that the newer combinations—particularly caudal with laparoscopy—do not compromise safety while offering modest time savings in the perioperative period.

Takeaways from this story

Caudal anesthesia with laparoscopy showed no increase in complications versus traditional general anesthesia with open repair
Caudal anesthesia shortened post-procedure time compared to general anesthesia regardless of surgical technique
Open surgery with caudal anesthesia was the most time-efficient combination, saving 9-15 minutes of total OR time
Two crossovers occurred: one infant could not tolerate pneumoperitoneum and one failed caudal despite passing pinch test

Keywords

inguinal hernia metachronous hernia strangulated hernia incarcerated hernia inguinal hernia repair open surgery laparoscopy general anesthesia caudal anesthesia regional anesthesia caudal blockade pinch test BC Children's Hospital Canadian Association of Pediatric Surgeons

Hashtags

#pediatricsurgery #inguinalhernia #laparoscopy #caudalanesthesia #generalsurgery #pediatricanesthesia #surgicaloutcomes #CAPs #LaparoscopicSurgery

Transcript

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.

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