Laparoscopic Cholecystectomy under Segmental Thoracic Spinal Anesthesia: A Feasible Economical Alternative

Abstract

Laparoscopic surgery is normally performed under general anesthesia, but regional techniques like thoracic epidural and lumbar spinal have been emerging and found beneficial. We performed a clinical case study of segmental thoracic spinal anaesthesia in a healthy patient. We selected an ASA grade I patient undergoing elective laparoscopic cholecystectomy and gave spinal anesthetic in T10-11 interspace using 1 ml of bupivacaine 5 mg ml⁻¹ mixed with 0.5 ml of fentanyl 50 μg ml⁻¹. Other drugs were only given (systemically) to manage patient anxiety, pain, nausea, hypotension, or pruritus during or after surgery. The patient was reviewed 2 days postoperatively in ward. The thoracic spinal anesthetia was performed easily in the patient. Some discomfort which was readily treated with 1mg midazolam and 20 mg ketamine intravenously. There was no neurological deficit and hemodynamic parameters were in normal range intra and post-operatively and recovery was uneventful. We used a narrow gauze (26G) spinal needle which minimized the trauma to the patient and the chances of PDPH, which was more if 16 or 18G epidural needle had been used and could have increased further if there have been accidental dura puncture. Also using spinal anesthesia was economical although it should be done cautiously as we are giving spinal anesthesia above the level of termination of spinal cord.

INTRODUCTION

Laparoscopic surgery is normally performed under general anesthesia, but regional techniques such as thoracic epidural and lumbar spinal have been emerging and found beneficial. We performed a clinical study of segmental thoracic spinal anesthesia in a 45-year-old healthy female patient using bupivacaine and fentanyl injected at T10-11 interspace; bupivacaine is the widely used local anesthetic in regional anesthesia. Addition of fentanyl decreases the dose requirement of bupivacaine and shortens onset time of block, so eliminating the side effects of larger doses of bupivacaine and also improves the quality of block.

CASE REPORT

After obtaining the Ethical Committee approval and written informed consent from a 45-year-old female, American Society of Anesthesiologists physical status I scheduled for laparoscopic cholecystectomy. Preanesthetic checkup was done a day before surgery; relevant investigations were done and informed written consent was taken. The patient was asked to remain nil per oral 8 h before surgery. The patient was premedicated with tablet alprazolam 0.5 mg and tablet ranitidine 150 mg in the night before surgery. Patient was preloaded with 500 ml lactated Ringer's solution. In operation theater, a good intravenous (IV) access was secured for preloading and a monitor was attached for monitoring electrocardiogram, heart rate (HR), noninvasive blood pressure, oxygen saturation (SpO₂), temperature, and respiratory rate. Patient was given injection ranitidine 50 mg and injection ondansetron 4 mg IV and was made to sit with their elbows resting on their thighs on operating table. Flexion of the spine was done and midline approach was used.

Segmental thoracic spinal anesthesia was given using 1 ml hyperbaric bupivacaine 5 mg/ml mixed with 0.5 ml of fentanyl 50 μg/ml injected at T10-11 interspace with a 26-gauge spinal needle after confirming its placement by free flow of clear cerebrospinal fluid [Figure 1]. Finally, the patient was turned to the supine horizontal position for the operation, and oxygen was started at 6 L/min by face mask. Onset of action and level of sensory block was judged by pin prick method every minute until the establishment of desired block. The overall quality of intraoperative muscle relaxation (poor, fair, good, or excellent) was evaluated by the surgeon at the end of the surgery. Hypotension was defined as systolic blood pressure <90 mmHg or >20% decrease in baseline values and was treated by fluids and vasopressors (mephentermine 6 mg). Bradycardia was defined as HR <50/min and was treated by 0.6 mg of atropine injection. HR, blood pressure, and SpO₂ were recorded every 3 min. Intra- and post-operative complications such as nausea, vomiting, pain, pruritus, headache, or any other side effects were recorded.

Figure 1.

Administering spinal anesthesia at T10-11 intervertebral space

Observations

The segmental thoracic spinal anesthesia was performed easily in the patient. Onset of sensory block T4-L2 required for minimally invasive laparoscopic cholecystectomy was achieved in 7 min and duration of block was 3 h. Surgery commenced using carbon dioxide insufflation and a pressure limit of 10–12 mmHg. Anxiety was treated with midazolam 1 mg and shoulder pain with 20 mg ketamine IV. There was no requirement of vasopressors and atropine during the surgery and the patient was hemodynamically stable during intraoperative and postoperative period. Furthermore, SpO₂ was above 96% at all-time intervals. Specific enquiry was made about postdural puncture headache (PDPH) which was not experienced by our patient, and the patient passed urine after the effect of block was over. Muscle relaxation was judged fair by the surgeon. Patient was followed for 48 h postoperatively in the ward and no complications were reported. Patient was examined for any remnant neurological deficit postoperatively and was not present.

DISCUSSION

This study has provided some preliminary indication of the feasibility of segmental thoracic spinal anesthesia in patients undergoing routine laparoscopic cholecystectomy and is certainly supportive of wider evaluation. The spinal anesthesia technique was performed at the low thoracic level with a 26-gauge spinal needle without any great difficulty, the T10-11 interspace[1] being chosen as lying in the “center” of the surgical field, although further work on the ideal space may be needed. van Zundert et al. used combined spinal epidural technique for the same procedure using bupivacaine and sufentanil in equivalent doses.[1] Ultrasonic guidance can also be used for insertion of spinal needle for better precision and safety.

Paresthesiae can occur with any technique of spinal anesthesia but are of potentially greater significance when the needle is inserted above the termination of the spinal cord. General consideration of the low potential for cord damage with this technique was given in the earlier case report.[2] However, we did not get paresthesia in our patient during needle insertion, occurrence of paresthesia implies contact with the neural tissue and in those cases needle should be withdrawn until the point where paresthesia disappears and then only anesthetic drug should be injected.[1,2] We used a narrow gauze (26-gauge) spinal needle which minimized the trauma to the patient and the chances of PDPH, which was more if 16- or 18-gauge epidural needle had been used and could have increased further if there have been accidental dura puncture. In addition, using spinal anesthesia was economical.

Our patient did not experience dyspnea during abdominal insufflation and SpO₂ was above 96% at all-time intervals, perhaps, because of the use of the horizontal position and low gas pressure. It is possible that the low dose of bupivacaine used was a factor that minimized the degree of thoracic motor block. Other side effects such as pain, nausea, vomiting, and pruritus were also not noted although we had to give 1mg midazolam for allaying anxiety and 20 mg ketamine for shoulder pain caused due to irritation of diaphragm by pneumoperitoneum intraoperatively, so low intrabdominal gas pressures were used.[3,4]

Injection at the thoracic level would have ensured that the opioid and the local anesthetic produced its highest concentrations in the surgically relevant segmental levels. Although managing postoperative pain have been easier with epidural technique with a catheter, in situ postoperative pain in laparoscopic cholecystectomy patients can also be managed with other analgesic modalities such as paracetamol, nonsteroidal anti-inflammatory drugs, and opioids.

CONCLUSION

This study has provided preliminary evidence that segmental thoracic spinal anesthesia can be an effective and economical anesthetic technique for routine laparoscopic surgery providing intraoperative hemodynamic stability with avoidance of complications of general anesthesia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.