Herniorrhaphy and orchiopexy are increasingly performed on an outpatient basis in paediatric surgery. In such cases, postoperative analgesia should receive special attention so that the hospital stay need not be unnecessarily prolonged due to side effects of the analgesic agents, such as sedation, respiratory depression or vomiting. Therefore, the present study is a randomized double-blind investigation to assess the effectiveness of atraumatic intra-operative instillation of bupivacaine in the surgical site and the rectal application of acetaminophen as a postoperative analgesic following herniorrhaphy and orchiopexy. Male patients between the ages of 3 and 6 yr who were scheduled to receive ambulatory herniorrhaphy or orchiopexy were included in the study. One hundred children in each of the herniorrhaphy and orchiopexy groups were treated respectively with acetaminophen or with bupivacaine as the postoperative analgesic. Atraumatic intraoperative instillation of bupivacaine into the surgical site proved to be significantly superior as a postoperative analgesic in both the herniorrhaphy and orchiopexy groups as compared to rectal application of acetaminophen (χ2 test: herniorrhaphy group P < 0.05; orchiopexy group P < 0.001). For herniorrhaphy and orchiopexy in childhood, local atraumatic instillation of bupivacaine during surgery into the wound bed is a simple, easy to use and reliable method for post-operative pain control with no side effects.

OBJECTIVE:The application of opiates after day case surgery in childhood is discussed controversially because of possible complications. Therefore many anaesthetists try to avoid these substances and prefer peripheral analgesics for postoperative pain control.METHODS:By distributing a questionnaire concerning the arguments connected with postoperative pain to 267 parents (a total of 78.3% of the questionnaires was returned) of children that had undergone inguinal herniorrhaphy or orchidopexy we hoped to gain insight into the judgement of peripheral analgesics-in this case acetaminophen-following inguinal herniorrhaphy or orchidopexy. During standardized anaesthesia the children received acetaminophen suppositories (15-20 mg/kg BW). After release from the hospital on the same day this drug was administered by the parents in case of necessity.RESULTS:Need for analgesics was significantly higher in the group of orchidopexy than in the group of herniorrhaphy (p < .01) and even memory of pain three days after the operation seemed to be higher in this group. The sleep patterns were more influenced by orchidopexy. Surprisingly 75% of the children following herniorrhaphy received no analgesics at all after release from the hospital (6 hours postoperatively).CONCLUSION:Following herniorrhaphy the postoperative pain therapy with acetaminophen seems to be sufficient. For the postoperative pain treatment after orchidopexy additional measures like local nerve blocks, regional anesthesia or wound infiltrations with local anaesthetics should be considered.

After minor day surgery carried out under a general anaesthetia in children in good general health, adequate pain therapy for the postoperative period can present problems. One reason for this is that postoperative pain is difficult to objectivize, especially in young children; a further point is that neither the anaesthetist nor the surgeon can monitor the effects and/or side-effects of the analgesic medication.

In the last seven years, the number of surgical procedures which are performed as day case surgery for infants and children has increased dramatically. Day case surgery should be able to be conducted effectively, with few complications, while saving time and money but also providing a pleasant atmosphere for the children and their parents. Since 1990, we have been practising day case surgery in the Department of Paediatric Surgery at the University of Tübingen twice a week. We have a special unit for this purpose with a team of day care personnel, paediatric nurses, anaesthesiologists and paediatric surgeons. The total number of operations performed in our department from 1990 to 1992 was 5330. Of these, 2111 (39.6%) were conducted as day case surgery for children of the ages six weeks to 20 years. The series includes 44 umbilical hernias, 385 phimoses, nine cervical cysts, 399 inguinal testes, 857 inguinal hernias, 90 hydroceles/funiculoceles, 19 haemangiomas, 43 meatotomies, 95 endoscopies and 170 other operations. Postoperative complications were defined as secondary haemorrhage, fever, obvious vomiting and urine retention. In a total of 35 (1.66%) children, the complications necessitated a stay in the hospital of up to eight (average 2.17) days, despite day case planning of the surgical procedure. Our experience shows that a large number of paediatric surgical procedures can be performed as day case surgery. Nevertheless, even with an expanded spectrum of possible operations there must always be ward capacities available in order to monitor and treat complications adequately.

To rationally discuss the "need for preoperative laboratory investigations prior to performing an operation that can be pre-planned", two questions must be considered: 1. What kind of complications were encountered during or after 25,872 anesthesias performed in a 20-year period? 2. What kind of diseases were recognized only postoperatively which apparently could not be diagnosed preoperatively via case history and clinical examination? The results of these analyses are tabulated and assessed. It could be shown that the case history and the clinical examination of the patient on the day of surgery rank before all laboratory tests. With regard to peroperative respiratory disturbances it could be proven that children within the first trimester are particularly susceptible to such alterations. Furthermore, it could be demonstrated that within this group premature babies are more susceptible to this kind of complication than babies born at date. With regard to the incidence of preoperative respiratory disturbances in children with or without infection of the upper respiratory tract, it was shown that children without such symptoms who had however undergone an infection three to four weeks before the operation, were more susceptible to peroperative respiratory disturbances than children without any infection or even children suffering from an acute infection. Taking the physiological Hb decrease at the end of the first trimester as an example, questions on the optimal date for surgery are discussed. Preoperative handling is discussed on the basis of the blood glucose level of 500 children after a fasting period of 3-4 hours.

294 parents whose children underwent day case surgery received a questionnaire covering the topics postoperative analgesia, memory of pain, sleep patterns and assessment of the time spent in the hospital. A total of 80.6% of the questionnaires were returned. We were not able to recognize any indications of behavioral disturbances, in particular disturbances of sleep. The need for analgesics was surprisingly low following release from the hospital. However, even on the third postoperative day 16.8% of the children still had unpleasant or strong memories of the pain they had experienced. Improvement in this area might be achieved by the application of nerve blocks, possibly in combination with analgesics. Further possibilities for improvement exist with premedication. The long waiting periods between hospital admittance and commencement of surgery were found to be very unpleasant. During surgery psychological counseling of the parents should be made possible.