Rev. Col. Anest. Mayo-Julio 2009. Vol. 37- No. 2: 111-118

Spinal anaesthesia for laparoscopic cholecystectomy

Patients and methods • Patients aged less than 18 and older than 75; -2 • Patients having greater than 30 Kg/m body A descriptive pros­pective study was carried out mass index (BMI); between June and September 2008 in the Caribe teaching hospital in the city of Cartagena in Co- • Sick patients having contraindication for lapa- lombia, South America. Once the Caribe teaching roscopic surgery; hospital’s medical ethics’ committee’s approval had • Patients having contraindication for spinal been sought and given, patients were included in anaesthesia; the study who had biliary lithiasis accompanied by a clinical picture of chronic cholecystitis as well as • Patients who preferred general anaesthesia; those having a clinical picture of subacute cholecys- and titis diagnosed during preoperative exam. • An inability for carrying out posto­perative follow- Patients who had been previously diagnosed as up. having complicated biliary lithiasis (acute chole- Inclusion criteria consisted of ASA I – II patients cystitis, choledocoli­thiasis, acute cholangitis, acute aged 18 to 75. All the patients complied with a biliary pancreatitis, etc.) were excluded. Other ex- minimum 8 hours fast; antibiotic prophylaxis was clusion criteria were as follows: 115 Anestesia espinal para colecistectomia laparoscópica - Jiménez J.C., Chica J., Vargas D. Rev. Col. Anest. Mayo-Julio 2009. Vol. 37- No. 2: 111-118 administered 15 minutes before the procedure (1 g tolerance to oral route had been produced and the intravenous cephazoline) anaesthesiologist had verified the absence of any type of complication. All patients were prescribed Anaesthetic technique ibuprofen as analgesia to be taken at home (400 mgr each 8 hours for 3 days). Telephonic follow-up was carried out by a surgical team after 24 hours and A peripheral vein in the forearm was canalized followed-up by external consultation after 7 and 30 with an 18-guage catheter. Endovenous liquid drip days. A person who was not part of the surgical team was begun (10 to 15 cc/kg of 0.9% SSN in bolus), made a phone call on the third day to ask about as were non-invasive blood pressure monitoring the degree of satisfaction regarding the procedure (sphygmomanometer on left arm), electrocar­ (being classified as excellent, good, regular and/or diography (electrodes on the thorax - 5 derivatives), poor) and to enquire whether the same anaesthetic oxime­try (finger pulse oximeter on the right arm) technique would be desired if further surgery were and capnography for measuring CO in respiratory 2 required. Other factors which were analysed are gases by nasal route. 4 mg dexamethasone was only given below: applied for postoperative anti-nausea and vomiting therapy. Spinal anaesthesia was produced by pla- Endogenous: age, gender, habits, weight, height cing the patient in a left lateral prone position; a and personal pathological background. Exogenous: midline puncture was performed at L2-L3 level with anaesthetics used (type, dose, frequency), surgical a 27-guage Quincke needle, in aseptic technique. A time, anaesthetic time, cardio-respiratory monito- 22.5 mg dose of bupivacaine levogira (7.5 mg/ml) ring, type of surgeon, required additional anaesthe- was injected following the egress of clear cepha- tic techniques, degree of pain, degree of satisfaction, lorrachidian liquid. The patient was then placed surgical complications, anaesthetic complications, in the Trendelenburg position with strict control presentation of undesirable clinical events, con- of dermatome sensitivity. When a sensory level version to general anaesthesia, required additional between T3-T4 was confirmed with cold swab, the postoperative analgesia, length of hospital stay, time patient was placed in a horizontal position. Oxygen spent on daily and work activities, the value of the was begun immediately by nasal cannula at 3.5 l/ anaesthetic and analgesic products consumed. min. Heart-beat, blood pressure and arterial oxygen Data analysis: EPI info 4.0 and Excel were used saturation were monitored every 2 minutes. 50mg/ for analysing the data. kg dipyrone + hyoscine bromide, 0.15 mg/kg meto- clopramide, 5 mg/kg ranitidine were administered at 15-minute intervals. Atropine (0.01 mg/kg) was Results applied if bradycardia was detected (heart-beat lower than or equal to 50 beats/min). 2 mg ethylephrine Forty-four patients suffering from vesicular was administered if blood pressure became reduced lithiasis were surgically treated during the study by 30% of base value. Midazolam (0.05 mg/kg) and period; 16 of them were submitted to emergency phentanyl (0.5 mg/kg) were used for sedation. surgery as they had acute clinical pictures. Two patients were excluded as they were older 75 and 1 The patient’s definitive position was inverted for being aged less than 18. Four patients preferred Trende­lenburg (30–45 degrees), involving left lateral general anaesthesia. The remaining 21 patients on prone position. Maximum intra-abdomi­nal pressure whom laparoscopic cholecystectomy was carried level was fixed at 12 mmHg with 2 L/min CO flow. 2 out under spinal anaesthesia formed the study Anaesthetic conversion was applied (i.e. applying population (Table 1.) general anaesthesia) if there were the presence of undesirable signs and symptoms which could not 85.7% of the patients were female. Average ove- easily be managed with intravenous medication. rall age was 40.4 years (19-67). Average body mass Sensory and motor recovery, degree of pain (0 to index (BMI) was 19 Kg/m-2 (16-23). 10 visual analogue scale), degree of satisfaction 3 90.5% of the patients were classified as being hours later (excellent, good, regular, poor), a need ASA I and juts 2 patients were ASA II. Inguinal her- for analgesia and the presence of undesirable events niorraphy was performed on one patient following such as nausea, vomiting, restlessness, abdominal laparoscopic cholecystectomy. 20% of the surgeries pain, pain in the shoulder (omalgia) were taken into were performed in their entirety by residents from account in the post-anaesthetic recovery room. If general surgery being trained in laparoscopic sur- such symptoms were presented, they were classified gery; they were being instructed by a laparoscopic (slight, moderate, severe). Patients were discharged surgeon. A vesicular cravat was diagnosed during once motor recovery, spontaneous dieresis and 116 Spinal anaesthesia for laparoscopic cholecystectomy - Jiménez J.C., Chica J., Vargas D. Rev. Col. Anest. Mayo-Julio 2009. Vol. 37- No. 2: 111-118

the intra-operative period and 2 patients presented procedures since its beginning and up to today. It firm adherences to the duodenum and colon. Avera- has been described that general anaesthesia minimi- ge surgical time was 29.3 minutes (25-40). No sur- ses the haemodynami­c and respiratory consequen- gical intra-operative­ or postoperative complications ces of pneumoperitoneum; tracheal intubation and were presented. Sensory anaesthetic block level was controlled ventilation will, in turn, reduce ventilatory

T4 in 50%, T3 in 50%. In no case was conversion to repercussions and the risk of regurgitation5. The in- general anaesthesia necessary. dication of general anaesthesia in laparoscopy would seem to be an irrefutable principle, given the safety it The following undesirable events were presented offers. However, this technique involves greater cost during surgery (Table 2): slight anxiety in 1 patient, than other anaesthetic techniques, postoperative slight omalgia in 5 of them, slight anxiety and omal- pain management is more complicated, it causes gia in 3 patients. These 9 patients were satisfactorily a higher incidence of postoperative nausea and managed with a 1 microgram/kg phentanyl dose. vomiting, needs neuromuscular block and involves Two-thirds of the patients required a single 2 low-quality reversion. Thus, as in surgery of the mg dose of ethylephrine and the other third 1 mg lower abdomen, anaesthesia with laryngeal masks of atropine as they presented a slight tendency to is beginning to be used instead of the habitual oro-

hypotension and bradycardia, respectively. Car- tracheal intubation, with encouraging results6. bon dioxide at the end of exhalation maintained Spinal anaesthesia for laparoscopic cholecystec- a 34 mmHg average, with 22 per minute average tomy was initially performed on patients suffering respiratory frequency. Four patients re­quired a from serious obstructive pulmonary diseases . Two single dose of endovenous analgesics during the 7 studies have been published recently which evalua- immediate postoperative period, 1 patient presen- ted the use of spinal anaesthesia in laparoscopic ted acute urinary retention which required vesicle cholecystectomy on “healthy” patients and other catheterisation and 1 patient presented an episode selected cases . Tzovaras et al., have reported 15 of vomiting without the need for medication. Sen- 8 patients submitted to laparoscopic cholecystectomy sory recovery was obtained after an average of 163 under spinal anaesthesia; it was possible to operate minutes (120-180) and motor recovery after 173 on all of them with this anaesthetic technique wi- minutes (160-180). The degree of postoperative pain thout the need to convert to general anaesthesia. after 2 hours received a 1.9 (1-3) average score. The The degree of postoperative pain during the first degree of satisfaction was reported as being excellent 24 hours was low and all (except for one patient) by 38% of the patients and good by 72% of them. strongly recommended this anaesthetic technique . Average hospital stay was 262.3 minutes (180-270). 7 A.A.J. Van Zundert et al., have published the results All patients were discharged before 4.5 hou­rs had from 20 patients submitted to cholecystectomy who elapsed, except for 2 of them; associated surgery for chose the laparoscopic route; they reported that the liberating adherences has been practiced on one of block was effective in all cases and only 6 patients them and she was discharged after 6 hours and the presented discomfort requiring a small dose of phen- other was intra-operatively diagnosed as suffering tanyl. Two patients required midazolam for treating from vesicular cravat, it being decided to administer anxiety and another two required ethylephrine for endovenous antibiotic therapy for one day. A third managing hypotension. No patient required conver- of the patients required additional doses of oral sion to general anaesthesia . The selection criteria analgesics after the third day following surgery. 7 for our preliminary series of 21 patients were simi- The average cost of anaesthetic products for spi- lar to those reported in previous studies. Patients nal anaesthesia was 15 dollars; the average cost for were selected with the aim of surgery being carried general anaesthesia for the same type of surgery at out rapidly and safely; the foregoing influenced the the same hospital is 30 dollars. 71.4% of the patients fact that the patients chosen were not elderly and were able to carry out daily activities after the third did not present an important concomitant disease. day following their operation and the average time However, as was expected, surgical time took a little for becoming reincorporated into their work was 9 longer as this is a teaching hospital where surgical days (7-15). All the patients responded positively residents are being instructed. to the question, “Would you wish to be operated on A significant percentage of cases required a sin- again with spinal anaesthesia?” gle, low dose of ethylephrine and atropine during surgery which did not in any way interfere with its Discussion development at any time. The foregoing suggested that pneumoperitoneum must be carried out slowly General anaesthesia has been the anaesthetic to prevent vagal reflex. Carbon dioxide at the end of technique of choice for most abdominal laparoscopic exhalation was monitored by nasal cannula in all 117 Spinal anaesthesia for laparoscopic cholecystectomy - Jiménez J.C., Chica J., Vargas D. Rev. Col. Anest. Mayo-Julio 2009. Vol. 37- No. 2: 111-118

patients and it was observed that normocapnia was of undesirable adverse events; recovery was rapid maintained with 18 to 22 per minute respiratory since factors such as maintaining the same local frequency, starting from 12 per minute frequen- anaesthetic dose and spinal block site determine

cies. We attribute this finding to the self-regulation more rapid recovery9. Early discharge was achieved

mechanism exercised by CO2 on respiration by the in nearly all most cases. For many years patients respiratory centre, this being an advantage given were discharged 24 hours after having been ope- the difficulty of ventilating these patients when they rated on; most patients are now being discharged are submitted to general anaesthesia. Even though once they have become alert, have spontaneous the self-regulation phenomenon is not enough for diuresis, tolerate a liquid diet and the surgeon has controlling hypercapnia, it is known that 15 to 30 ruled out any postoperative complication (for more

min must elapse for PCO2 to reach plateau condi- than 1 year now). Almost all patients are currently tions. The surgical procedure was carried out by being discharged 4 hours after their operation (as surgical interns and surgical time was extremely reflected in the present series). acceptable, thereby permitting suitable PCO levels. 2 The costs of the anaesthetic products required for Low intra-abdominal pressure was another relevant spinal anaesthesia at the hospital in question are factor, meaning that our series was actually being twice as inexpensive as those required for general evaluated with arterial gases for monitoring PCO 2 anaesthesia; the foregoing is mainly due to the hig- in blood and correlating this with the value from her cost of the inhalatory and muscular relaxants monitoring gases by nasal cannula. The results used in our setting. This preliminary series has thus have been encouraging to date. It should be stres- shown that spinal anaesthesia could be a safe and sed that the anaesthetic block was carried out in inexpensive technique for the surgical treatment of all cases by residents from anaesthesiology, being vesicular lithiasis by laparoscopic route in selected instructed by anaesthesiologists having great ex- patients, even though there is need for randomised perience in using high blocks (mammaplasty, open clinical assays comparing this technique with re- cholecystectomy, etc). Sensory and motor recovery gional and general anaesthesia in our hospitals for in the immediate postoperative recovery period was obtaining more conclusive data. as expected, with low pain indices and presence

referencIAs

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118 Spinal anaesthesia for laparoscopic cholecystectomy - Jiménez J.C., Chica J., Vargas D.