teenage years or may have been the subject of an improper and poor surgical tech­nique due to lack of access to skilled medical and surgical care [4]. Most patients with this disorder will undergo multiple corrective surgical procedures in their life­time to achieve functionally and cosmetically acceptable results [9].

Regardless of the surgical approach, approximation of the pelvis, either through manual approximation of a still malleable pelvis among neonates or through pelvic osteotomies for older children, is essential for abdominal closure and for the likeli­hood of achieving continence [10]. There is a need for extended immobilization postoperatively to promote healing and to maintain pelvic ring integrity. This in turn requires adequate pain management, nutritional support, meticulous nursing care for osteotomy sites, surgical drains and stents, and skin integrity.

Optimal outcomes from such a complex surgery with a prolonged postoperative course involving neonates, young children, or adolescents requires a close interdis­ciplinary perioperative collaboration between surgeons, anesthesiologists, intensiv­ists, pediatricians, experienced nursing staff, and physical therapists. The surgical correction requires extensive reconstructive procedures to restore anatomical integ­rity, and the functional outcomes depend signicantly on meticulous perioperative management, including adequate pain management, minimizing complications, and optimizing recovery.

Preoperative evaluation is crucial in determining the overall health status of the patient and identifying any comorbidities that may impact the perioperative man­agement. The surgical candidates most commonly fall into one of three categories: neonates, older children, and children with previously failed surgeries or complica­tions related to previous surgery.

For older children, preoperative assessment by an anesthesiologist should also include assessment of preoperative anxiety, stress, and fear, as it has been demon­strated to have detrimental effects on intraoperative analgesic and anesthetic use, postoperative pain scores, analgesic requirements, as well as behavioral and sleep disturbance [4, 12, 13]. Management of preoperative anxiety may include age- and development-appropriate behavioral modalities such as preoperative preparation programs providing orientation tours and narrative information, coping and self­management skills such as relaxation and distraction techniques, therapeutic play, toys, art, music, games, and visual aids such as videos, books, and virtual reality [14]. Acupuncture and acupressure have also been shown to reduce preoperative anxiety [15, 16]. The administration of anxiolytics in the United States varies based on the age of the patient and geographical location. The most commonly used anx­iolytic medications include midazolam (85% of patients), fentanyl, ketamine, cloni­dine, or dexmedetomidine, especially when analgesia is also desired or midazolam is contraindicated [14]. The premedication is usually administered orally, but intra­nasal, intravenous, and intramuscular routes can also be utilized.

Standard American Society of Anesthesiologists (ASA) monitoring (pulse oxime­ter, electrocardiography (ECG), noninvasive blood pressure, temperature, end-tidal carbon dioxide (ETCO2), inspired oxygen concentration), and neuromuscular blockade are essential. Often in HICs, invasive intra-arterial blood pressure (IABP) monitoring is routinely done, especially for neonates. Obtaining adequate vascular access with two large-bore peripheral intravenous catheters is essential for rapid volume replacement.

neonates, infants, and children [18]. In neonates and infants, the use of epidural analgesia has contributed to limiting postoperative opioid-related adverse effects, facilitating earlier tracheal extubation, and quickening the resumption of normal gastrointestinal function [19, 20].

Induction of general anesthesia may be achieved using either an inhalational or intravenous route. After induction of general anesthesia and endotracheal intuba­tion, an epidural catheter is placed that should cover the low thoracic to sacral der­matomes, thus requiring a relatively large spread of local anesthetic. Catheters can be inserted in the sacral, caudal, or lumbar region. Caudal insertion requires advancement of the catheter tip to the lumbar region [17, 21]. In young infants, blind advancement of the catheter can be achieved in two-thirds of the patients [21]. Correct positioning can be conrmed by epidurogram, which involves injecting a small amount of contrast through the catheter during either uoroscopy or x-ray, or by using ultrasound to approximate the spread of the local anesthetic. Although not FDA approved for use in the USA, special catheters for placement at the desired location are available, such as the Tsui stimulating or electrocardiography catheter [22, 23].

In our practice (AK and AY), an epidural catheter is initially inserted in the mid­line via a caudal or lumbar approach through a Touhy epidural needle using the loss of resistance to saline technique to locate the epidural space, and the catheter is advanced to the desired position. To tunnel the epidural catheter, then using the Touhy needle, we identify a trajectory and distance for the tunneled portion of the epidural catheter starting from the exit site of the epidural catheter in the midline and extending it in a lateral and cephalad direction to where the desired exit location of the tunneled part of the catheter is. Then the Touhy needle along with its stylet is inserted at the identied tunneled exit point and advanced under the skin in a cau­date and medial direction such that it should exit adjacent to the epidural catheter without damaging it. The stylet is removed, and the epidural catheter is now fed through the epidural needle, ensuring that the catheter does not kink or knot. Finally, the Tuohy needle is withdrawn, and the length of the catheter is gently pulled at its exit site, usually below the iliac crest, until it lies at under the skin at the initial insertion site. Preferably, a transparent adhesive dressing is applied to the initial

After an initial bolus dose, a continuous infusion of local anesthetic with or with­out opioids or other adjuvants, such as low-dose alpha-2 agonists (clonidine or dex­medetomidine), can be infused intraoperatively through the epidural catheter and continued postoperatively. In neonates, administration of bupivacaine or ropiva­caine (1mg/kg) or chloroprocaine (30 mg/kg) as a bolus can be followed by an infusion rate no higher than 0.4mg/kg/h for ropivacaine or bupivacaine and 10mg/ kg/h for chloroprocaine [18, 20, 26]. While epidural infusions of 0.2mg/kg/h of bupivacaine were associated with rising serum levels after 2days of epidural infu­sions [27, 28], this is not true of ropivacaine [29]. Therefore, either chloroprocaine or ropivacaine infusions are the safest options for neonates and infants under 180days of age [26, 29–32]. In older patients, either bupivacaine or ropivacaine can be infused safely at a rate of up to 0.6mg/kg/h [7, 17, 19].

At the conclusion of the surgery, the goal should be to extubate these children after the reversal of the neuromuscular blocking agents. Due to the prolonged use of neuromuscular blocking agents intraoperatively, quantitative monitoring of the neu­romuscular blockade and reversal is ideal for minimizing chances of postoperative residual neuromuscular blockade and respiratory insufciency [49, 50].