A comparison of the cost of local versus general anesthesia for laparoscopic sterilization in an operating room setting

LLETZ make it simple: Anxiety, pain and treatment outcomes with outpatient large loop excision of the transformation zone under local anaesthesia

BACKGROUND

Large loop excision of the transformation zone (LLETZ) is the preferred treatment for cervical intraepithelial neoplasia due to its effectiveness and ability to be performed in an outpatient setting under local anaesthesia (LA). Although current guidelines recommend that most LLETZ can be performed under LA, there is paucity in clinical data of patients' perspectives of outpatient LLETZ.

AIM

Determining patient acceptability of outpatient LLETZ through assessment of anxiety and pain scores, and comparing treatment outcomes with current standards in terms of margins status, negative histology, short-term morbidity rates and follow-up attendance.

MATERIALS AND METHODS

This study was conducted at a tertiary hospital over two years (2014-2016). Patients undergoing outpatient LLETZ completed a three-part questionnaire (before, immediately after and 4-6 weeks post-procedure).

RESULTS

One hundred and five patients underwent outpatient LLETZ. Mean pain score was 2 (range 0-8). Pre-procedure anxiety was common but most resolved post-procedure. Women who did not have a prior LLETZ discussion were more likely to report moderate-severe anxiety levels pre-procedure, compared with women who did (odds ratio 3.00, 95% CI 1.11-8.09, P = 0.030). There were no differences found in pain scores when comparing pre-procedure anxiety levels, prior discussion of LLETZ or mode of anaesthesia. Specimen margins were involved in 42.9%. No association was found between positive cervical margin status and age, pre-procedure anxiety or post-procedure pain scores. Most patients were satisfied and attended follow-up appointments.

CONCLUSION

Large loop excision of the transformation zone under LA is a well-tolerated procedure with high satisfaction and follow-up rates. Clinicians need to initiate early discussions regarding treatment to minimise procedure-related anxiety.

Laparoscopic Sterilization Under Local Anesthesia with Conscious Sedation Versus General Anesthesia: Systematic Review of the Literature

Female sterilization is the most popular and common contraceptive method worldwide. Because hysteroscopic sterilization techniques are used less often due to side effects, the number of laparoscopic sterilization is increasing. A systematic overview concerning the most optimal anesthetic technique for laparoscopic sterilization is lacking. We performed a systematic review to compare conscious sedation with general anesthesia for laparoscopic sterilization procedures with respect to clinical relevant outcome measures, such as operating times, perioperative parameters and complications, patient comfort, recovery, and patient satisfaction. We searched Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE for randomized controlled trials comparing general anesthesia with conscious sedation for laparoscopic sterilization. Two authors (AGH and HAAMvV) abstracted and entered data into RevMan. Methodologic quality of the included trials was critically appraised. For our main outcome measures mean differences (continuous variables) and risk ratios (dichotomous variables) with 95% confidence intervals using random-effect models were calculated. Four randomized controlled trials were included comparing general anesthesia versus local anesthesia with conscious sedation for laparoscopic sterilization. The methodologic quality of the studies was moderate to good. Both techniques were comparable with regard to operating times, complications, and postoperative pain. However, local anesthesia with conscious sedation showed better results compared with general anesthesia with respect to recovery times, patient complaints of sore throat, and patient recovery and satisfaction. In conclusion, this systematic review about anesthetic techniques for laparoscopic sterilization showed that both general anesthesia and conscious sedation have no major anesthetic complications and may therefore be safe. Patients might benefit from conscious sedation in terms of recovery times, sore throat, and patient recovery and satisfaction, but only a few studies are included in the review and are relatively old. New research regarding this subject is needed to advise our patients most optimally in the future about the best anesthetic technique to be used when choosing for a laparoscopic sterilization procedure.

A mixture of 86% of CO2, 10% of N2O, and 4% of oxygen permits laparoscopy under local anesthesia: a pilot study

The aim of this study is to verify that 10 % of N₂O in CO₂ sufficiently reduces pain to permit laparoscopy under local anesthesia. In nine patients undergoing laparoscopy under local anesthesia for tubal sterilization, a mixture of 86 % of CO₂, 10 % of N₂O, and 4 % of oxygen (the Gas Mixture) was used for the pneumoperitoneum. For CO2, N₂O, and for the Gas Mixture, the pain when blowing over the tongue tip and the pH changes of saline and Hartmann’s solution were estimated. In all nine patients, discomfort was minimal and the intervention was well tolerated, similar to 100 % N₂O. Tongue tip pain (n = 15), on VAS scale, was lower with 86 % CO₂ + 10 % N₂O + 4 % O₂ (2.4 ± 1.4, P = 0.005) and much lower with 100 % N₂O (0.3 ± 0.6, P < 0.0007) than with pure CO₂ (3.6 ± 1.7). The pH of saline (n = 5) decreased from 7.00 ± 0.07 to 4.18 ± 0.04 (P = 0.001), 6.98 ± 0.08 (NS), and 4.28 ± 0.04 (P = 0.01) with 100 % CO₂, 100 % N₂O and the Gas Mixture_, respectively. The pH of Hartmann’s solution (n = 5) decreased similarly from 7.00 ± 0.07 to 5.18 ± 0.04 (P = 0.01), 7.02 ± 0.19 (NS), and 5.3 ± 0.4 (P = 0.01), respectively. These data demonstrate that a mixture with 10 % of N₂O and 4 % of O₂ in CO₂ permits laparoscopy under local anesthesia. This result cannot be explained by direct irritation estimated by tongue tip pain or by pH changes.

Regional anesthesia for laparoscopic surgery: a narrative review

Laparoscopic surgery has advanced remarkably in recent years, resulting in reduced morbidity and shorter hospital stay compared with open surgery. Despite challenges from the expanding array of laparoscopic procedures performed with the use of pneumoperitoneum on increasingly sick patients, anesthesia has remained largely unchanged. At present, most laparoscopic operations are usually performed under general anesthesia, except for patients deemed "too sick" for general anesthesia. Recently, however, several large, retrospective studies questioned the widely held belief that general anesthesia is the best anesthetic method for laparoscopic surgery and suggested that regional anesthesia could also be a reasonable choice in certain settings. This narrative review is an attempt to critically summarize current evidence on regional anesthesia for laparoscopic surgery. Because most available data come from large, retrospective studies, large, rigorous, prospective clinical trials comparing regional vs. general anesthesia are needed to evaluate the true value of regional anesthesia in laparoscopic surgery.

Microlaparoscopic tubal ligation under local anesthesia

Local anesthesia to perform laparoscopic tubal ligation is of increased interest due to potential safety and cost benefits. We performed tubal ligation using microlaparoscopic techniques with local anesthesia and continuous intravenous sedation in 16 women desiring sterilization. Operating and recovery times and patient satisfaction were recorded and compared with values for 30 similar women undergoing microlaparoscopic tubal ligation under general anesthesia. Mean +/- SD operating and recovery times for local and general anesthesia were 29.3+/- 8.1 versus 33.6 +/- 11.1 minutes, and 83.9 +/- 59.4 versus 114.5 +/- 69.8 minutes, respectively. Patient satisfaction was high. The potential for cost savings when performed in an outpatient or clinic setting is significant.