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Summary We report laparoscopic sleeve gastrectomy in five awake obese patients, completed under regional anaesthesia provided by paravertebral and superficial cervical plexus blockade. The technique was acceptable to patients, surgeons and anaesthetists.

We compared the analgesic and anaesthetic efficacy of pudendal nerve block with that of dorsal penile nerve block in male patients aged 3-5 years of age, undergoing elective circumcision. Thirty patients had a nerve stimulator-guided pudendal nerve block with two separate injection points 1.5-2 cm from the centre of the anus, and thirty patients received a dorsal penile nerve block. The same total anaesthetic volume of 0.3 ml.kg(-1) was used in both groups. The pudendal nerve group showed significantly lower postoperative pain scores than the dorsal group (SD) (p < 0.05), and significantly fewer patients consumed analgesics in the pudendal group than the dorsal group: 0 vs 5 (17%) at 0 and 6 h, respectively. This study demonstrates the effectiveness of pudendal nerve block in comparison to the dorsal nerve block, with improved postoperative outcomes in children undergoing circumcision.

Summary The aim of this study was to compare the efficacy of nerve stimulator guided paravertebral block with ilio-inguinal nerve block in children undergoing inguinal herniorrhaphy. Eighty children were randomly allocated to receive either paravertebral block or ilio-inguinal nerve block. Each block was evaluated in terms of intra-operative haemodynamic stability, postoperative pain scores at rest, on movement and during activity, requirement for supplemental analgesia and parental satisfaction. Haemodynamic stability was maintained significantly better during sac traction in the paravertebral block group (p < 0.005). Pain scores and analgesic consumption were significantly lower in the paravertebral block group during the postoperative follow-up period (p < 0.05). Parental satisfaction (93% vs 69%) and surgeon satisfaction (93% vs 64%) were significantly higher in the paravertebral block group (p < 0.05). Paravertebral blockade improved and prolonged postoperative analgesia, and was associated with greater parental and surgeon satisfaction when compared to ilio-inguinal nerve block.

A fundamental requirement for the safe and effective performance of paravertebral blockade is reliable estimates of the depth from skin to paravertebral space at different thoracic levels. This distance was assessed using a nerve stimulator guided paravertebral blockade technique in 527 separate blocks in 186 patients scheduled for various surgical procedures on the trunk. The median skin-paravertebral depth was 55.0 mm. The skin-paravertebral distance at upper (T1-3) and lower (T9-12) thoracic levels were significantly greater than mid-thoracic levels (T4-8) (p < 0.05). Body mass index significantly influences this depth at upper and lower thoracic levels (p < 0.001) but not in the mid-thoracic region.

Sixty patients scheduled for pilonidal sinus surgery were prospectively randomly assigned to receive general anaesthesia or sacrococcygeal local anaesthesia with a newly-described technique. Patients in the general anaesthesia group spent more time in the operating theatre and recovery room than did those in the local anaesthesia group (p < 0.05). Two thirds (67%) of the patients in the local anaesthesia group left hospital on the day of surgery compared to only 17% of patients in the general anaesthesia group (p < 0.05). Visual analogue scale pain scores performed during the 3-day follow-up period favoured the local anaesthetic technique (p < 0.05). Postoperative analgesia requirements were greater in the general anaesthesia group than in the local anaesthesia group (p < 0.05). The majority of patients and surgeons expressed satisfaction with local anaesthesia. Sacrococcygeal local anaesthesia appears to be a successful alternative to general anaesthesia for pilonidal sinus surgery.

We compared the analgesic and anaesthetic efficacy of pudendal nerve block with that of dorsal penile nerve block in male patients aged 3-5 years of age, undergoing elective circumcision. Thirty patients had a nerve stimulator-guided pudendal nerve block with two separate injection points 1.5-2 cm from the centre of the anus, and thirty patients received a dorsal penile nerve block. The same total anaesthetic volume of 0.3 ml.kg(-1) was used in both groups. The pudendal nerve group showed significantly lower postoperative pain scores than the dorsal group (SD) (p0.05), and significantly fewer patients consumed analgesics in the pudendal group than the dorsal group: 0 vs 5 (17%) at 0 and 6 h, respectively. This study demonstrates the effectiveness of pudendal nerve block in comparison to the dorsal nerve block, with improved postoperative outcomes in children undergoing circumcision.

The factors responsible for the spreading pattern of a single paravertebral injection are still uncertain. In this study, 28 patients were randomly assigned to receive a paravertebral injection of radio-opaque dye (10 ml, with or without co-administration of 20 ml of local anaesthetics) either dorsal or ventral to the endothoracic fascia. The point of injection was determined by use of a nerve-stimulator and the radiographic distribution pattern was assessed blindly by a radiologist. Injections made in the more ventral part of the thoracic paravertebral space, supposedly anterior to the endothoracic fascia, resulted in a multisegmental longitudinal spreading pattern, whereas injections made dorsal to the endothoracic fascia resulted in a less predictable cloud-like spreading pattern, with only limited distribution over adjacent segments. The use of a nerve stimulator-guided technique appears to enhance the likelihood of achieving the more desirable longitudinal spreading pattern.

The failure rate and complications following thoracic and lumbar paravertebral blocks performed in 620 adults and 42 children were recorded. The technique failure rate in adults was 6.1%. No failures occurred in children. The complications recorded were: inadvertent vascular puncture (6.8%); hypotension (4.0%); haematoma (2.4%); pain at site of skin puncture (1.3%); signs of epidural or intrathecal spread (1.0%); pleural puncture (0.8%); pneumothorax (0.5%). No complications were noted in the children. The use of a bilateral paravertebral technique was found approximately to double the likelihood of inadvertent vascular puncture (9% vs. 5%) and to cause an eight-fold increase in pleural puncture and pneumothorax (3% vs. 0.4%), when compared with unilateral blocks. The incidence of other complications was similar between bilateral and unilateral blocks.