|Year : 2019 | Volume
| Issue : 3 | Page : 261-265
General anesthesia versus spinal anesthesia in laparoscopic cholecystectomy: safety, feasibility, and affordability in rural hospital in India
Utpal K Ray1, Ranjan Bhattacharyya2
1 Department of Anaesthesiology, Murshidabad Medical College & Hospital, Baharampur, West Bengal, India
2 Department of Psychiatry, Murshidabad Medical College & Hospital, Baharampur, West Bengal, India
|Date of Submission||05-Nov-2017|
|Date of Acceptance||12-Dec-2018|
|Date of Web Publication||29-Aug-2019|
DNB (Psychiatry), MNAMS Ranjan Bhattacharyya
29, Anandasree, Garia, Kolkata 700084, West Bengal
Source of Support: None, Conflict of Interest: None
General anesthesia (GA) is the choice for laparoscopic cholecystectomy (LC). Spinal anesthesia (SA) is usually preferred in patients where GA is contraindicated. In this study, SA was used in 67 patients in whom LC was planned (study group). LC has been conventionally done under GA. Regional anesthesia is usually preferred in patients where GA is contraindicated. SA was used in 67 patients for LC (study group). Moreover, 50 patients were given GA as a control group. There was no modification in the technique, and the intra-abdominal pressure was kept at 8–10 mmHg. Sedation was given if required, and conversation to GA was done in patients not responding to sedation or with failure of SA. Of 67 patients, two patients required conversation to GA. Hypotension requiring support was recorded in 14 (20.89%) patients and 16 (23.88%) experienced neck or shoulder pain or both. Postoperatively, two (2.9%) patients had vomiting as compared 17 (34%) patients who were administered GA. Injectable diclofenac was required in 25 (37.3%) patients for abdominal pain within 2 h postoperatively and oral analgesic for 53 (79.10%) patients within the first 24 h in SA group. However, 96% of patients operated under GA required injectable analgesics in the immediate postoperative period. Postural headache was experienced by five (7.46%) patients postoperatively. The average time of discharge was 1.9 in patients operated under SA compared with 2.1 days in GA group. There is no risk of intubation-related airway obstruction, little risks of unrecognized hypoglycemia in a diabetic patient, excellent muscle relaxation, decreased surgical bed oozing, and a more rapid return of gut function when LC is done using SA compared with GA.
Keywords: general anesthesia, laparoscopic cholecystectomy, rural areas, spinal anesthesia
|How to cite this article:|
Ray UK, Bhattacharyya R. General anesthesia versus spinal anesthesia in laparoscopic cholecystectomy: safety, feasibility, and affordability in rural hospital in India. Res Opin Anesth Intensive Care 2019;6:261-5
|How to cite this URL:|
Ray UK, Bhattacharyya R. General anesthesia versus spinal anesthesia in laparoscopic cholecystectomy: safety, feasibility, and affordability in rural hospital in India. Res Opin Anesth Intensive Care [serial online] 2019 [cited 2020 Apr 5];6:261-5. Available from: http://www.roaic.eg.net/text.asp?2019/6/3/261/265732
| Introduction|| |
General anesthesia (GA) remains the choice for most open abdominal surgical procedures, and regional anesthesia is preferred for patients who are at high risks under GA. For the past 6 years, we have been doing almost all our open abdominal surgeries, including surgery of the upper abdominal surgeries and surgery of the upper abdominal organs like the stomach and hepatobiliary system, under spinal anesthesia (SA). The main reason for selecting SA as the first choice for laparoscopic cases was its advantages over GA, which include uniform total muscle relaxation, a conscious patients, economical, relatively uneventful recovery, pain-free early postoperative period, and avoidance of the potential complications of GA. It was thus logical that we shifted to SA for all laparoscopic cholecystectomy (LC) cases.
The worldwide literature until approximately 5 years ago suggested only GA as the anesthetic option for abdominal laparoscopic surgery being performed, with select patients under spinal or epidural anesthesia having started to appear. This was a retrospective study of LC while under SA since 2012 at Murshidabad Medical College & Hospital, West Bengal, India.
| Patients and methods|| |
This retrospective study was carried out at Murshidabad Medical College and Hospital from July 2014 to June 2017. Approval from IEC committee taken and written informed consent had been obtained from the patients and/or their legal guardians. The ethical approval has been taken from the Institutional Ethics Committee. Written informed consents had been taken from the patients or their legal guardians. The American Society of Anaesthesiologist grade I and grade II patients undergoing laparoscopic abdominal procedures were offered SA as the first choice. Since 2014, 67 patients have undergone abdominal LC under SA. Patients who preferred GA or had contraindication for SA, like children less than 10 years age, deformity of spine, cardiac problems, and skin pathology overlying the spinal site, were operated under GA and were taken as controls. In the study group, 13 had acute cholecystitis and had to be taken for emergency LC, whereas 51 underwent elective cholecystectomy. Preoperatively, preloading with 1000-ml Ringer’s lactate was done, and patients were premedicated 45 min before surgery with glycopyrrolate 0.2 mg intramuscularly+diazepam 10 mg or midazolam 5 mg intramuscularly +diclofenac Na 3 ml (25 mg/ml). Injection of ranitidine 50 mg intravenously and injection of metoclopramide 10 mg intramuscularly were given. SA was administered using a 25 FG or 26 FG lumber puncture needle in L1-L2 intervertebral space. Three milliliters to 5 ml of sensorcaine (Bupivacaine HCl 5 mg+sodium chloride 8 mg/ml) was used. Head down tilt 10–20° was kept for 5 min. The segmental level achieved was T4-T5 to enable introduction of epigastric port. The patients were monitored for blood pressure, SpO2, SpCO2, and heart rate. Patients’ anxiety was defined as anxiety that resulted in inability to complete the procedure under SA and requiring conversation to GA. During surgery, oxygen supplementation was optional and administered through a ventimask, at the rate of 5 l/min only in patients with SpO2 below 95%. In patients complaining of neck pain, shoulder pain or both, tramadol 25 mg or Fortwin 15 mg was administered as slow intravenous or in drips. In patients who still had persistence of pain, Ketamine 25 mg was administered as slow intravenous dose. If the patient was still anxious, conversation to GA was done. Bradycardia below 50/min was managed by 0.3–0.6 mg atropine intravenous or 0.2 mg glycopyrrolate. Hypotension, defined as a fall in blood pressure of greater than 20% of original blood pressure at any time after SA during or after surgery, was managed by 3–6 mg mephentermine intravenous intermittently up to a maximum of 15 mg, and subsequent persisting hypotension was managed by dopamine 4–6 μg/kg/min during the operative period or in the postoperative period or during both, until the stabilization of blood pressure occurred. The virtue of providing excellent anesthesia by spinal and epidural anesthesia in LC has been limited by hypotension arising during it, largely owing to sympathetic blockade. Although sympathomimetic amines with vasoconstrictor (alpha adrenergic activity) are used to treat hypotension in SA, the vasoconstriction caused by the dopamine may lead to reduced blood flow in visceral organs. On one hand it is beneficial to reduce perioperative blood loss and in hypertensive patients but severe hypotension may produce myocardial and cerebral ischemia.
The laparoscopic procedure was carried out in the standard fashion with fours port without any modification. The peritoneal pressure was kept between 8 and 12 mmHg. The postoperative parameter evaluated (in nonsedated patients) included operative site pain, assessed by a verbal numeric pain scale: no pain, mild bearable pain not requiring any medication, moderate pain, and severe pain, both requiring medication. The other parameters included urinary retention, headache, and the incidence of postoperative vomiting. These were compared with corresponding parameters of 50 patients undergoing LC under GA.
Owing to the influences on respiratory system caused by pneumoperitoneum, the GA under controlled ventilation is one of the accepted methods of LC nowadays. The anesthetic drugs like intravenous propofol and etomidate and inhalation agents like desflurane and sevoflurane, which are rapidly acting and have a shorter duration of action, had been used for LC under GA. Although nitrous oxide has the advantage of decreasing incidence of postoperative nausea and vomiting (PONV), it has not been used here. In the group of nonobese patients undergoing LC under GA, the laryngeal mask airway had been used. In most cases, GA with endotracheal intubation with maintenance of end-tidal carbon dioxide intraoperatively around 35 mmHg is performed.
| Results|| |
This retrospective study included 67 patients who underwent LC under SA, and 50 patients who underwent LC under GA between July 2014 and June 2017. In SA group, 52 patients were females, and the rest were males. The average age was 42.1 years in GA group. A total of 39 patients were females and 11 patients were males, and the average age was 40.2 years. In SA group, acute cholecystitis with cholelithiasis was the indication for LC in 19.4% of cases against 14% in GA group. In the rest of the patients in both groups, LC was performed for chronic cholecystitis with cholelithiasis.
Average operative time required in elective LC was 28.6 min in SA group and 32.6 min in GA group. During emergency LC under SA, a mean 41.6 min was needed, whereas 42.6 min in GA group. The difference was insignificant. During operation under SA, 14 patients had hypotension and 16 had anxiety/neck and shoulder pain. Stomach distention requiring insertion of Ryle’s tube was noticed in three patients in SA group against 41 patients in GA g group. The difference was significant (P<0.01). Two patients of SA group had to be given GA owing to failure of SA in one and neck and shoulder pain in another, which was not relieved by drugs ([Table 1],[Table 2],[Table 3]).
|Table 1 Profile of patients in spinal anesthesia and general anesthesia groups|
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|Table 2 Operating time in spinal anesthesia and general anesthesia groups|
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|Table 3 Perioperative effects of spinal anesthesia and general anesthesia groups|
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The incidence of vomiting and pain treated with injectable analgesics or with oral drugs was significantly more in patients of GA groups than SA groups (P<0.01). The incidence of urinary retention was more in SA group (P<0.01). Headache was experienced by five patients in SA group only. Postoperative stay on an average was 1.9 days in SA group and 2.1 days in GA group, and the difference was insignificant ([Table 4]).
| Discussion|| |
Regional anesthesia is seldom used in abdominal laparoscopic surgeries except for diagnostic laparoscopies. The prime indication for regional anesthesia in therapeutic laparoscopies is still limited to patients unfit for GA, and the preferred type of regional anesthesia. Thus reports of laparoscopic surgery being done with patients under SA are even scarcer than those of patients under epidural anesthesia ,.
We have been performing most of our open abdominal surgeries primarily with patients under SA for the past 8 years. Rarely in upper abdominal surgeries, especially those focused on the cardio-esophageal junction or liver, supplemental sedation or conversation to GA is required. It was thus logical that after performing the initial few laparoscopic surgeries using GA in 2009, we shifted to SA as the anesthesia of choice for all our abdominal laparoscopic procedures. The optimal anterior abdominal wall relaxation and conscious and receptive patient under SA together with our experience of SA in open cholecystectomies for last 8 years inspired us to try SA for all laparoscopy cholecystectomy cases (LCS). Another reason for preferring SA was preventing the potential complication of GA. The initial concern was never the subcostal level of anesthesia (T4-T5) for the epigastric and subcostal ports, because we had been successfully making upper abdominal incisions in open abdominal surgeries without discomfort to the patient. The pneumoperitoneum-induced rise in intra-abdominal pressure including pressure on the diaphragm and carbon dioxide induced peritoneal irritation were the factors to be considered. These factors could be overcome by changes in methodology of port site placement and using nitrous oxide, which is less irritating for the peritoneum compared with carbon dioxide, and maintaining low intraperitoneal pressure of 8 mmHg when using SA, which has been reported to reduce the discomfort chances of neck and shoulder pain . This agrees with a recent report by Tzovaras and colleagues. Surprisingly, neck pain and shoulder pain have never been a major problem in our patients . They occurred in only 23.88% of patients in our study for which injection ketamine had to be given. One of them required conversation to GA. Pursnani et al.  noted that shoulder and neck pain occurred in two of six patients operated under epidural anesthesia, and they were easily managed. On the contrary, in the series of Hamad et al. , of 310 LC performed under SA, only one patient had to be given GA because of intolerable shoulder pain. Chui et al.  noted shoulder pain one in of 11 patients of bilateral spermatic varices operated under epidural anesthesia. The other reasons for conversation in the study was incomplete effect of SA. Conversation to GA because of abdominal distension and discomfort during epidural anesthesia was reported in one of 11 patients by Chui et al. . One of six patients in the study by Ciofolo et al.  required conversion to an open procedure because of uncontrolled movements under epidural anesthesia.
The potentiality of intubation and ventilation-related problems including an increase in mechanical ventilation to achieve an adequate ventilation pressure exits during GA as compared with SA.
The pneumoperitoneum-induced rise in intra-abdominal pressure could be another cause of hypotension. When we compared hypotension figures recorded in 14 (20.89%) patients with figures in patients undergoing open surgery with SA, we found a comparable picture. Thus, although Hartmann et al.  reported hypotension in 5.4% of their SA patients, Palachewa et al.  found an incidence of 15.7%, Throngnumchai et al.  found an incidence of 20.2%, and Hyderally  reported an incidence of 10–40%. This then conclusively proves that the incidence of hypotension is no different whether laparoscopic surgery or open surgery is being done with SA and that an intraperitoneal pressure of between 8 and 10 mmHg does not add to the problem of decrease venous return and persistence of hypotension. Although Chui et al.  have mentioned that a high SA block up to T2-T4 may cause myocardial depression and reduction of venous return, this was never substantiated in our series. An added cardiovascular advantage cited has been the decrease in surgical bed oozing because of hypotension bradycardia, and improved venous drainage associated with SA .
GA patients unlike SA patients frequently have an additional problem of stomach inflation as a result of mask ventilation. This often requires Ryle’s tube insertion, which amounts to unnecessary intervention in a body cavity.
The main debatable point, however, seems respiratory parameters among the two modes of anesthesia during laparoscopic surgery. In this context, it can be stated that spontaneous respiration during SA would always be better than an assisted respiration.
In addition, pulmonary function takes 24 h to return to normal after laparoscopic surgery under GA . However, the observation are not uniform, and conflicting reports of respiratory parameter alterations in patients under regional anesthesia and GA are present. On the contrary, Chui and colleagues reported a significant arterial blood gas alteration during epidural anesthesia. Ciofolo et al.  concluded that the epidural anesthesia for laparoscopy does not cause any respiratory depression.
In the present study, none of the patients had any significant variation in PaO2 or PaCO2 during the surgery with SA.
Perioperative shoulder pain never persisted in the postoperative period. In the postoperative period after SA, there was no restlessness as commonly seen after GA and the patient is always receptive and more complaint to the suggestions. A specific advantage of SA seems to be decrease in the requirement of postoperative analgesia. Injectable diclofenac was required by 37.3% of SA patients for their abdominal pain as compared with 96% of GA group. Injectable analgesic was required between 2 and 6 h after surgery in SA, whereas within 2 h after extubation in GA patients. Postural headache was seen in 7.46% of patients of SA group which persisted for an average of 2.3 days and responded when the patient was made to lie down and with an increased intake of fuilds and salt. Complication of SA in LC is less seen as compared with the study of Palachewa and colleagues. Headache was not observed in GA groups. There was a significantly high incidence of urinary retention in patients operated under SA. Complications like sore throat, relaxant induced muscle pain, dizziness, and PONV often create high morbidity after GA. The problem was seen in 2.9% of our SA group but has been reported as high as 8.1% in study by Sinha et al. . However, PONV is highest after GA, especially when nitrous oxide, opiate, or reversal agents are used ,. Even with the newer agents like propofol and isoflurane, the incidence of PONV is as high as 30%, and they substantially increase the cost of anesthesia. Our GA patients had an incidence of 34% of PONV, which was significantly higher compared with that in SA patients. Another important advantage of SA is that other complication specific to GA including cardiac, myogenic, and general complication do no occur with SA. Mobilization and ambulation in both SA and GA patients was achievable within 8–12 h after surgery. Karnofsky performance status showed a 95–100% satisfaction level in 98% of the patients. This means the patient was happy and would probably reomended this approach to friends. This is actually true because a sizeable number of our patients now actually demand that they be operated on while under SA.
| Conclusion|| |
There is no risk of intubation-related airway obstruction, little risks of unrecognized hypoglycaemia in a diabetic patient, excellent muscle relaxation, decreased surgical bed oozing, and a more rapid return of gut function when LC is done using SA compared with GA. This is in addition to the obvious advantages in an old patient or those with COPD or other systemic disease like hepatic and renal disease and diabetes.
LC done with the patients under SA has several advantages over LC done with the patients under GA.
The authors are thankful to all the staff members, internees, and residents of the Department of Anesthesia and Surgery for their support. The authors are also thankful to our patients to be a part of our study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]