Original Research Article Ultrasound-guided ilioinguinal and iliohypogastric nerve block (IINB) versus subarachnoid block (SAB) for inguinal mesh hernioplasty: A prospective randomized comparative clinical study Gautam Kumar Goel1, Gopal Krishan2*, Malti Agrawal3, Ram Pal Singh3, Sarfraj Ahmed4, Chandra Prakash Pandey5 {1Junior Resident, 2Associate Professor, 3Professor, 4Assistant Professor, Department of Anaesthesiology} {5Professor, Department of General Surgery} RMCH Bareilly, INDIA. Email: [email protected] Abstract Background: Many anaesthetic techniques have been used for inguinal mesh hernioplasty. The use of regional anaesthesia techniques are the most satisfactory methods for high risk patients who are unfit for general or spinal anaesthesia. Aims and objectives: The aim of this study was to compare the effectiveness, safety, and complications of ultrasound guided ilioinguinal and iliohypogastric nerve block with subarachnoid block for inguinal mesh hernioplasty. Materials and Methods: This study was carried out on 60 patients of ASA Grade I or II undergoing mesh hernioplasty. Group A patients received ultrasound guided ilioinguinal and iliohypogastric nerve block with 25 ml of 0.5% isobaric levobupivacaine. Group B patients received subarachnoid block with 3 ml of 0.5% isobaric levobupivacaine. Onset and duration of sensory blockade was studied in both the groups. Motor power was assessed at 5 minutes and just postoperatively in both the groups.All patients were sedated using continuous propofol infusion. Results: Postoperative ambulation was significantly earlier in group A patients. Patients in Group A had better hemodynamic stability when compared with group B. Conclusion: Ultrasound guided ilioinguinal and iliohypogastric nerve block under sedation is a better alternative anaesthetic technique for inguinal mesh hernioplasty in high risk patients. Key Words: Ilioinguinal, Iliohypogastric, Levobupivacaine, Propofol, Ultrasound. *Address for Correspondence: Dr Gopal Krishan, Associate Professor, Department of Anaesthesiology, RMCH, Bareilly, INDIA. Email: [email protected] Received Date: 07/07/2020 Revised Date: 12/08/2020 Accepted Date: 17/09/2020 DOI: https://doi.org/10.26611/10151613 This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Access this article online INTRODUCTION Many anaesthetic techniques have been used for inguinal Quick Response Code: mesh hernioplasty. The choice of the anaesthetic technique Website: depends on its acceptability by the patient and surgeon, the www.medpulse.in feasibility and safety of the procedure, surgical method, medical history, co morbidities, and the cost. Epidemiological data have found that general anaesthesia Accessed Date: (GA) is used in 60–70% of cases, central neuraxial block in 10–20%, and regional anesthesia techniques with 14 October 2020 1,2 sedation in 5–15% of the cases. The use of local anaesthesia (LA) techniques is the most convenient method for patients who are unfit for general or spinal anaesthesia due to cardiovascular disease, cerebrovascular How to site this article: Gautam Kumar Goel, Gopal Krishan, Malti Agrawal, Ram Pal Singh, Sarfraj Ahmed, Chandra Prakash Pandey. Ultrasound-guided ilioinguinal and iliohypogastric nerve block (IINB) versus subarachnoid block (SAB) for inguinal mesh hernioplasty: A prospective randomized comparative clinical study. MedPulse International Journal of Anesthesiology. October 2020; 16(1): 11-16. http://medpulse.in/Anesthsiology/index.php MedPulse International Journal of Anesthesiology, Print ISSN: 2579-0900, Online ISSN: 2636-4654, Volume 16, Issue 1, October 2020 pp 11-16 disease, severe respiratory disease, severe liver oblique and the transversus abdominis. After negative impairment, or coagulopathies. Ultrasound guided aspiration, 25 ml of 0.5% isobaric levobupivacaine was Ilioinguinal and iliohypogastric nerve block may be used deposited between the transversus abdominis and the for inguinal hernia repair surgeries as well as postoperative internal oblique. After local anaesthetic injection, the split analgesia.3,4 Direct sonographic visualization of the widens because of spread of the drug. In group B, under all ilioinguinal and iliohypogastric nerves improve the quality aseptic precautions, the patients were given subarachnoid of the block, increases success rate to 95%, and reduces the block with 3 ml of 0.5% isobaric levobupivacaine, between risk for complications, whereas the conventional technique the L3 and the L4 intervertibral space in sitting position of ilioinguinal and iliohypogastric nerve block is with the help of 27 G quincke type spinal needle. The associated with a failure rate of 40%. The postoperative propofol infusion was started at the rate of 25 microgram requirements for additional analgesics are significantly /kilogram/minute in both the groups. lower in the ultrasound guided nerve block technique Exclusion criteria - compared with the conventional blind fascia click Patient refusal. Coagulopathy. Allergy to Local technique.5,6,7 The use of intravenous sedation increases Anaesthetic or any included medications. Severe liver, the acceptability of local anaesthetic techniques. renal, or cardiovascular diseases. Recurrent, bilateral, Moreover, it improves the success rate of the block. irreducible, incarcerated, or large scrotal hernias. Infection Propofol sedation provides rapid recovery due to rapid at the site of injection. Psychiatric disorder. Obesity (BMI distribution and short elimination half-life. The brief >35). Lengthy operation duration of more than120 min. duration of action ensures prompt responsiveness to Neurological disease. Severe deformities of the spinal change in its infusion rate and could easily be maintained column, such as severe kyphoscoliosis, arthritis, and at the desired level of sedation by varying the infusion rate. previous lumbar fusion surgeries. The use of propofol decreases the level of postoperative Sample size was estimated before study using duration of sedation, drowsiness, and confusion. 8,9,10,11 motor blockade as a primary outcome. A sample size of 60 patients was required at α =0.05, β =0.001 and power of MATERIALS AND METHODS study 95%. Statistical analysis of the data was done using After approval from the institutional ethical committee, the the statistical package for the social sciences (SPSS 22.0) present one year study was conducted in the department of using independent t-test to determine mean significant anaesthesiology, Rohilkhand Medical College and difference between the two variables. p<0.05 considered as Hospital, Bareilly starting from November 2018 to statistically significant and p < 0.001 considered as October 2019. The current study was carried out on 60 statistically highly significant. The data was compiled patients of American Society of anesthesiology class I or using Microsoft excel sheet (windows 2010). II. Patients with recurrent, bilateral, irreducible, or large Measurements scrotal hernias were excluded. The patients were randomly Age and weight of the patients and the surgery duration divided into two equal groups using the computer- were measured. Onset and duration of sensory blockade generated random sequence of numbers. All patients were was recorded. The total amount of intraoperative propofol evaluated the evening before surgery and informed on consumed in each group was measured. Assessment of whether they will be undergoing ultrasound guided motor power was carried out 5 min after the block and ilioinguinal and iliohypogastric nerve block or immediately postoperatively using the modified Bromage subarachnoid block and how the procedure will be Scale (Table 1). Ambulation time was also documented. performed in either technique. All patients were trained to use visual analogue scale (VAS) to express their pain. All Table 1: Modified Bromage Scale 0 No paralysis, able to flex hips/knees/ankles patients received a sedating dose of Midazolam (2–3 mg) 1 Able to move knees, unable to raise extended leg before the procedure. Group A (n=30): All patients 2 Able to flex ankles, unable to flex knees received ultrasound guided ilioinguinal and 3 Unable to move any part of the lower limb iliohypogastric nerve block with 25 ml of 0.5% isobaric Heart rate and mean arterial blood pressure (MABP)were levobupivacaine. Group B (n=30): All patients received recorded before induction of anesthesia, after induction, 5 subarachnoid block with 3 ml of 0.5% isobaric min and then every 15 min intraoperatively, and 30 min, 1 levobupivacaine. In group A, patients, under all aseptic h, and every 4 h for the first 24 h postoperatively. precautions, a linear ultrasound probe with 10 Hz Postoperative pain was assessed at 30 min, 1 h, and every frequency at a depth of 3 cm from skin was placed at the 4 h postoperatively for 24 h using the Visual Analogue anterior superior iliac spine in an oblique manner at the line Scale (0–10), in which 0=no pain and 10=severe possible joining the umbilicus and the anterior superior iliac spine. pain. The time of first need for rescue analgesia and the The nerves lie in the fascial split between the internal total rescue analgesia doses were recorded. Total propofol MedPulse International Journal of Anesthesiology, Print ISSN: 2579-0900, Online ISSN: 2636-4654, Volume 16, Issue 1, October 2020 Page 12 Gautam Kumar Goel, Gopal Krishan, Malti Agrawal, Ram Pal Singh, Sarfraj Ahmed, Chandra Prakash Pandey used intraoperatively was recorded. Postoperative sedation