Comparison of General Anesthesia and Combined Spinal and Epidural Anesthesia for Gasless Laparoscopic Surgery in Gynecology

Background and Objectives

Laparoscopic surgeries in gynecologic field have been performed under general anesthesia (GA) due to the respiratory changes caused by pneumoperitoneum and Trendelenburg position. Therefore, this study aimed to compared general anesthesia and combined spinal and epidural anesthesia (CSEA) for gasless laparoscopic surgery in gynecologic field.

Methods

We matched patients with type of surgery who underwent gasless single port access (SPA) laparoscopic surgery under general anesthesia and CSEA. The medical records of 90 patients between March 1, 2018 and June 30, 2020 were reviewed. Gasless laparoscopic surgery was performed in all patients with a SPA using a J-shaped retractor.

Results

No significant differences were observed for age, body mass index, parity, and previous abdominal surgery between GA and CSEA groups. During operation under CSEA, six patients (20%) experienced nausea/vomiting. Hypotension (systolic blood pressure < 90 mmHg) was observed in five patients (16.7%). Intravenous analgesics was administrated in four of the patients (13.3%) who suffered from shoulder pain or abdominal discomfort. One patient developed bradycardia. The duration of hospital admission was shorter in the CSEA group than in the GA group (p = 0.014). There was no difference between the groups in terms of surgery type, surgical specific finding, operation time, estimated blood loss, laparotomy conversion rate and use of additional trocar. No major complications such as urologic, bowel, or vessel injuries were found in both groups.

Conclusions

CSEA is a safe and feasible technique for application in nonobese patients undergoing gasless laparoscopic surgery in gynecologic field.

Efficacy of combined spinal and epidural anesthesia vs epidural anesthesia alone in total hysterectomy: Impact on serum motilin and gastrin

AIM

To compare the efficacy of combined spinal and epidural anesthesia vs epidural anesthesia in total hysterectomy and the impact on the serum motilin and gastrin.

METHODS

Ninety-two patients who underwent total hysterectomy at Zhejiang Cancer Hospital from September 2015 to January 2016 were selected and randomly divided into two groups to receiver either combined spinal and epidural anesthesia or epidural anesthesia alone, with 46 cases in each groups. The two groups of patients were compared for intraoperative parameters, serum motilin and gastrin, patients' heart rate, mean arterial pressure, and awakening time, and intraoperative complications.

RESULTS

Time to successful induction of anesthesia was significantly shorter and use of anesthetics was significantly less in the combination group than in the epidural anesthesia alone group (P < 0.05). There was no significant difference in operative time between the two groups (P > 0.05). Before anesthesia, serum motilin showed no significant difference between the two groups (P > 0.05); after anesthesia, the combination group had a more obvious decrease (P < 0.05). Serum motilin exhibited a transient increase intraoperatively, but declined at day 1 postoperatively in both groups; the decrease was more significant in the combination group (P < 0.05). Serum gastrin showed no obvious change throughout the process in both groups, and there was no statistically significant difference between the two groups at all time points (P > 0.05). After anesthesia, the combination group was superior to the epidural anesthesia alone group with regard to heart rate, mean arterial pressure, and awaking time, and the difference was statistically significant (P < 0.05). The incidence of complications (6.52%) was significantly lower in the combination group than in the epidural anesthesia alone group (19.57%, P < 0.05).

CONCLUSION

Combined spinal and epidural anesthesia for total hysterectomy is safer and more effective and has fewer complications than epidural anesthesia alone. However, serum motilin and gastrin levels are unstable in both groups, and reducing perioperative surgical stress will have a positive impact on serum motilin and gastrin levels.

Effect of different anesthesia and analgesic methods on recovery of gastrointestinal function in elderly patients after open surgery

AIM

To explore the effect of different anesthesia and analgesia methods on gastrointestinal function recovery in elderly patients after open surgery.

METHODS

A total of 100 elderly patients undergoing open surgery from April 2016 to December 2017 were selected and divided into a control group (n = 50) and an observation group (n = 50) according to the method of anesthesia and analgesia. In the control group, systemic intravenous anesthesia and meridian analgesia were used. In the observation group, combined spinal and epidural anesthesia and epidural analgesia were used. Time to first defecation, time to recovery of gastrointestinal peristalsis, and time to food intake were recorded. Immunoradiometric method was used to determine plasma motilin levels before and after anesthesia and analgesia. The visual analog scale (VAS) was used to evaluate the pain degree of the two groups before anesthesia and analgesia and 6 h, 12 h, 18 h and 24 h after anesthesia and analgesia. The incidence of complications such as nausea and vomiting, elevated blood pressure, abnormal liver and kidney function, and post-cognitive dysfunction (POCD) were also recorded.

RESULTS

Time to first defecation, time to recovery of gastrointe-stinal peristalsis, and time to food intake in the observation group were significantly shorter than those in the control group (P < 0.05). Plasma motilin levels in the observation group after anesthesia and analgesia were significantly higher in the observation group than in the control group (P < 0.05). VAS scores at 6 h, 12 h, and 18 h after anesthesia and analgesia were significantly lower than those before anesthesia and analgesia in both groups, and were significantly lower in the observation group than in the control group (P < 0.05). The incidence of nausea and vomiting, diarrhea, elevated blood pressure, abnormal liver and kidney function, and POCD was significantly lower in the observation group than in the control group (P < 0.05).

CONCLUSION

The combination of lumbar-sparing anesthesia and epidural analgesia in elderly patients undergoing laparo-tomy can promote the early recovery of gastrointestinal function and reduce pain, and has a low incidence of postoperative complications.

A case report of intracranial hemorrhage after spinal anesthesia

Background

Chronic subdural hematoma (CSDH) after spinal anesthesia is a rare complication. We experienced a patient who developed CSDH after postdural puncture headache (PDPH) following combined spinal and epidural anesthesia (CSE).

Case presentation

A 38-week-gestation parturient with a history of previous cesarean delivery underwent elective cesarean section under CSE. She had been receiving aspirin therapy for Kawasaki disease for many years. She developed a symptom of PDPH 1 day after the surgery. Fluid administration and analgesics were started. Although the headache was relatively severe and persistent, it suddenly disappeared on the third postoperative day. Aspirin administration was restarted on the third postoperative day, and the patient was discharged 1 week after the surgery. 2 weeks after being discharged, she was readmitted to our hospital for severe headache and was diagnosed as having CSDH. An epidural blood patch was performed, resulting in resolution of the hematoma.

Conclusions

We experienced a case of CSDH after PDPH in a patient who was receiving aspirin therapy. Aspirin therapy should be restarted after confirmation of the absence of headache. We should consider the possibility of unexpected disappearance of PDPH in the postoperative period may be due to the development of CSDH.

Major laparoscopic surgery under regional anesthesia: A prospective feasibility study

BACKGROUND

Laparoscopic surgeries have attained the status of a gold standard for most of the abdominal pathology; we therefore performed this study to assess feasibility and safety of major laparoscopic surgeries like laparoscopic cholecystectomy (LC) and laparoscopic assisted vaginal hysterectomy (LAVH)/total laparoscopic hysterectomy (TLH) under regional anesthesia that is combined spinal epidural anesthesia (CSE) with normal pressure pneumoperitoneum using intrathecal fentanyl with bupivacain.

METHODS

In a zonal government hospital, 50 patients were selected prospectively for LC and LAVH/TLH, under normal pressure (12 mmHg) pneumoperitoneum and under CSE over a span of fifteen months. Injection bupivacaine (0.5%) and 20 μg of fentanyl were used for spinal anesthesia. Plain bupivacaine (0.5%) was used for epidural anesthesia.

RESULTS

We successfully performed the operations in 48 patients without major complications. CSE was converted to general anesthesia in two patients due to distressing shoulder tip pain. Age varied between 25 and 70 years. Duration of operation time (skin to skin) was between 50 and 170 min. Five patients had urinary retention and one developed localized pruritis. There was no incidence of respiratory depression, aspiration or headache.

CONCLUSION

Laparoscopic surgeries with normal pressure CO2 pneumoperitoneum are feasible and safe under CSE. Incidence of postoperative shoulder pain was minimal due to use of intrathecal fentanyl and complications were less and easily manageable.