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Spinal Anaesthesia for Laparoscopic Cholecystectomy

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Spinal Anaesthesia for Laparoscopic Cholecystectomy 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 oxime try (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 Trende lenburg (30–45 degrees), involving left lateral general anaesthesia. The remaining 21 patients on prone position. Maximum intra-abdomi nal 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 haemodynami c 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 re quired 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
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