SummaryFifty-two boys undergoing herniotomy, orchidopexy or ligation of patent processus vaginalis under general anaesthesia had supplementary analgesia; 26 had a caudal epidural block and 26 an ilioinguinal block. Analgesia was assessed both during and afer surgery. Ilioinguinal block provides a useful alternative to caudal block. Key wordsPain; postoperative. Anaesthetic techniques; caudal, ilioinguinal.There is a continuing search for satisfactory methods of pain relief after surgery. Techniques need to be safe, with a low incidence of side effects, reliably effective and to produce analgesia of adequate duration. It is also advantageous if the technique is simple and without later complications.Caudal block using bupivacaine administered after induction of general anaesthesia but prior to surgery is widely used to provide analgesia during and after operation for lower limb surgery, circumcision and groin surgery in children. However, there is a risk of side effects with this technique,' such as motor block, bladder hesitancy and postural hypotension. Ilioinguinal block, for the relief of post herniotomy pain in children, has been advocated by both Shandling and Steward2 and Smith and Jones.3 A blind, prospective study was undertaken to compare the quality of analgesia both during and after operation provided by these techniques. The incidence of side effects was also recorded. MethodsFifty-two fit boys (ASA 1) aged between 1 and 12 years due to undergo herniotomy, orchidopexy or ligation of patent processus vaginalis, were admitted to the study. The patients were age matched and randomly assigned to one of two groups, A or B. Group A patients were to have a caudal block and group B an ilioinguinal block. All patients were seen pre-operatively by the anaesthetist. Premedication consisted of oral diazepam 0.5 mg/kg to a maximum of 20 mg. The mood of each child was S

Aim U-stitch laparoscopic gastrostomy is a commonly used technique for placement of balloon gastrostomy for pediatric patients. The U-stitch method was modified by others whereby the stay sutures are placed in a subcutaneous tissue. Although this modification has been reported to be superior, it has led to suture knot abscess formation which was not reported in the original method. We developed further modification whereby the stay-suture knots are positioned within the gastrostomy tract instead of the subcutaneous tissue which minimizes suture knot abscess formation. Methods Modified U-stitch technique was used to place the balloon gastrostomy. The U-stitch stay sutures are placed to hold the stomach to the abdominal wall. These sutures are subcutaneously tunneled toward the gastrostomy tract and tied to the opposing sutures with the resulting knots lying within the tract of the gastrostomy. Chart reviews of patients who underwent this modified U-stitch method were done. Results A total of 27 consecutive patients were evaluated. Minimal follow-up period was 6 months. No suture knot abscess complication was found. One patient for whom we used a polyglactin (Vicryl; Ethicon Inc., Cincinnati, Ohio, United States) suture developed cellulitis around the gastrostomy site which cleared with antibiotic. Remaining 10 patients for whom we used Vicryl suture and 16 patients for whom polydioxanone (PDS; Ethicon Inc.) suture was used did not develop any infections. Conclusion Subcutaneous placement of stay suture within the open gastrostomy tract rather than within closed subcutaneous tissue may minimize suture knot abscess formation.

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Consensus statements and regulatory guidelines endorse the process of identifying patients at increased risk for surgical morbidity and mortality. This is termed prognostic testing, and it identifies patients who are deemed to be too sick to benefit from the anticipated gain of surgery. However, much more valuable than prognostic testing is predictive, or directive, testing. A predictive test pinpoints the patient’s problem that will benefit from a specific available intervention. This review covers what is risk?, changing paradigms of surgical success, building a case for moderation, so, does anyone disagree?, timing, frailty and age (and the eyeball test), is the heart the only organ that counts?, changing paradigms, the enhanced importance of functional capacity, resting electrocardiogram, exercise stress testing, ventricular function testing, stair climbing: putting it all together, pulmonary function tests, obstructive airway disease, perioperative nutrition, how can we make surgery safer?, enhanced recovery after surgery, putting it all together, extended enhanced recovery after surgery, tight glucose control, smoking cessation, and timing of collaboration with anesthesia. Figures show routine preoperative tests for elective surgery (adapted from the National Institute for Health and Care Excellence clinical guideline 3, preoperative assessment strategies and recommended risk-reducing therapy relative to American Society of Anesthesiologists (ASA) classification performed by the surgeon and age, ASA Class I and II patients may be safely be evaluated by an anesthesiologist on the day of their scheduled surgery for a full preoperative history and physical examination, flow volume loop. Tables list ASA physical status classification, effect of abnormal screening results on physician behavior, and minimum preoperative test requirements at the Mayo Clinic (in 1997).   This review contains 4 highly rendered figures, 3 tables, and 111 references