In this prospective randomized study, the patients will be enrolled based on the inclusion and exclusion criteria. All the patients eligible for the study will undergo a preoperative assessment and will be explained thoroughly about the study. A detailed patient information sheet will be given to these selected patients. Written informed consent in vernacular language will be taken prior to the study from all the patients participating in the trial. The study will start once the patient arrives in the preoperative room. Preoperative instructions on how we will assess the perioperative pain using Numeric rating scale (NRS) from 0 (no pain) to 10 (worst pain), will be explained to patients. Intra-venous access will be obtained before arrival in operation theatre.

The preoperative Numerical Rating Scale pain scores at rest and at 15 ° leg elevation will be recorded. Under all aseptic precautions, Group A patients will receive Ultrasound-guided PENG block and SIFICB and Group B patients will receive Ultrasound guided PENG block alone in the preoperative room in supine position  as described below.

Technique of PENG block

The patient will be positioned supine. The block will be performed under absolute aseptic precautions using a low-frequency Ultrasound probe with an echogenic peripheral nerve block needle (Stimuplex Ultra). In order to perform the block, the low-frequency probe of the Ultrasound machine (Sonosite Fujifilm Inc. USA) will be positioned parallel to the inguinal ligament at the level of the anterior superior iliac spine (ASIS), and scanning will proceed with a gradual movement of the probe caudally, keeping the probe parallel to the inguinal ligament. When the lower anterior inferior iliac spine (AIIS) is visible, the probe will be moved medially in such a way that a continuous hyperechoic shadow of the upper pubic ramus is seen. This method will identify the iliopsoas muscle, which has a conspicuous tendon immediately above the pubic ramus. The target plane to deposit local anaesthetic is between the pubic ramus and iliopsoas tendon (hyperechoic structure just above the pubic ramus). Using the in-plane approach, the 22G, 10 cm long, echogenic needle will be advanced in the musculofascial plane between the psoas tendon and the pubic ramus, lateral to the medial side. Hydro dissection and spread under the illo-psoas muscle will reveal the needle’s precise site and 20ml of 0.2% ropivacaine will be injected.(14)

Technique of SIFICB - This block will be accomplished with a high-frequency linear ultrasonic transducer probe (Fujifilm sonosite USA) under aseptic precautions. The patient will be positioned supine to perform the block.  The probe will be positioned in the para-sagittal plane over the inguinal ligament near the anterior superior iliac spine. The thick white line of the ilium will first be detected, followed by the more superficial, black (hypoechogenic) iliacus muscle with the fascia iliaca covering its surface then the probe will be moved inferior and medially until you visualise the anterior inferior iliac spine and bow tie sign (confluence of oblique muscle one side and sartorius on another side over the fascia iliaca). The deep circumflex iliac artery, which gives a landmark for needle placement, can be located superficial to the fascia iliaca 1-2 cm superior to the inguinal ligament. The needle (Stimuplex ultra) will be inserted through the in-plane technique (caudal to cranial), and will be moved through the fascia iliaca at the inguinal ligament level. The needle frequently makes a ’pop’ when it traverses through the fascia iliaca and enters the iliacus muscle . Through the process of hydro-dissection, the needle will be advanced superiorly, deep into the fascia iliaca. The local anaesthetic must be able to spread across the surface of the iliacus muscle freely. When the local anaesthetic freely travels superiorly across the iliacus muscle, and into the iliac fossa, the endpoint will be achieved. At this site, a total of 20 mL of ropivacaine 0.2% will be administered.(3)

The NRS at rest and with 15° leg elevation will be measured 10 min later after the completion of both blocks. Standard ASA monitors will be attached electrocardiogram (ECG), pulse oximetry (SpO2), non-invasive blood pressure (NIBP); on their arrival in operation theatre.

The Ease Of Spinal Positioning (EOSP) will be assessed on the scale of 0–3 (0 = unable to position, 1 = patient had abnormal posturing due to pain and required support for positioning, 2 = mild discomfort but does not require support for positioning, 3 = optimal condition where the patient was able to position himself without pain).(11) Subarachnoid block will be performed with 15 mg bupivacaine (3 ml of a 0.5% solution) after confirming free flow of cerebrospinal fluid to achieve sensory block at or above T10 dermatome.

Intraoperative fluids and blood will be administered according to the requirement. After the surgery, all patients will be transferred to the post-anesthesia care unit (PACU) and will be given a 1gm dose of intravenous paracetamol, followed by 8 hourly in the postoperative period. We will assess pain levels using the Numeric Rating Scale (NRS) at rest and with 15° leg elevation in the PACU, as well as at 6, 12, 18, and 24 hours after the surgery. If NRS >/=4 then inj fentanyl 25 mcg bolus will be given to the patients. Post operatively, we will monitor the patients hemodynamic parameters, NRS pain scores, duration of pain relief (the time from completing both procedures to the patient’s first dose of rescue pain relief) and the total analgesic consumption over 24hrs will be recorded.(3)