J Am Assoc Gynecol Laparosc 1994 Aug;1(4, Part 2):S36
Lutheran General Hospital, 1875 Dempster, #245, Park Ridge, IL 60068.
Gasless laparoscopy is an evolving technique which can offer significant advantages to both patient and surgeon. A variety of major laparoscopic operations can be performed with gasless surgery including oophorectomy, myomectomy, and hysterectomy. The use of conventional instrumentation and open ports significantly improves the ease of surgery and greatly facilitates techniques such as endosuturing. For those patients with a contraindication, or a fear of general anesthesia, gasless laparoscopy under a regional anesthetic is now a reasonable alternative. A laparoscopic-assisted vaginal hysterectomy was performed with gasless technique under continuous epidural anesthesia. The surgery was completed without complication, and the patient expressed a high degree of satisfaction. Subsequently, three additional patients have successfully undergone major laparoscopic operations using a gasless technique and epidural anesthesia. With careful patient selection and attention to proper technique, gasless laparoscopy under regional anesthesia is a safe and viable alternative to conventional CO2 laparoscopy.
J Laparoendosc Surg 1992 Dec;2(6):281-286
Department of Laparoendoscopic Surgery, Staten Island University Hospital, NY.
The endoscopic extraperitoneal hernioplasty as reported in this study is a similar repair to that achieved by the conventional preperitoneal repair as described by Stoffa, Nyhus, and Rignault. However, this new repair is completed via a totally extraperitoneal approach. Thus, it eliminates all early and late complications related to the violation of the peritoneal cavity as proposed by other intraperitoneal laparoscopic approaches to hernia repair. This report demonstrates the safety and feasibility of this procedure while offering the patient the advantages of a minimally invasive surgical procedure which can be performed under regional anesthesia.
Fertil Steril 1985 May;43(5):809-810
Regional anesthesia, in selected cases, is a useful alternative method of providing anesthesia for the retrieval of oocytes when general anesthesia is not indicated. We report our experience in managing anesthesia in four patients in whom we used a subarachnoid block. Ova were obtained in three patients, and two became pregnant and delivered healthy full-term infants. Although the high pregnancy rate was noted with delight, it is clearly a statistical happenstance. It would be interesting, however, to carry out prospective studies to determine whether a relationship between the incidence of pregnancy and anesthetic method might exist.
J Am Assoc Gynecol Laparosc 1995 Aug;2(4, Supplement):S75
Pelosi Women's Medical Center, 350 Kennedy Blvd., Bayonne, NJ 07002.
Standard laparoscopic surgery during pregnancy may be associated with adverse effects for the mother and fetus secondary to general anesthesia and the creation of pneumoperitoneum. I developed a technique of gasless, single-umbilical puncture laparoscopy under epidural anesthesia that can be performed during pregnancy. It eliminates the need for general anesthesia and intraperitoneal gas insufflation, thereby avoiding potential complications associated with their use.
J Am Assoc Gynecol Laparosc 1995 Aug;2(4, Supplement):S79
Surgeons are generally reluctant to perform laparoscopic surgery during early pregnancy because of increased intraabdominal pressure with carbon dioxide insufflation, bleeding from engorged pelvic vasculature, potential for trauma to the uterus, and the need for general anesthesia. A 32-year-old woman, gravida 2, para 1, underwent gasless laparoscopy under epidural anesthesia at 14 weeks' gestation to remove an ovary containing a 9-cm dermoid cyst. A mechanical abdominal wall elevator eliminated the need for pneumoperitoneum. Conventional laparotomy instruments were used, which enhanced eye-hand dexterity and technique. The procedure was completed within 70 minutes, and the patient was discharged within 24 hours after surgery.
Anesth Analg 1997 Jan;84(1):65-70
Department of Anaesthesia, Vancouver Hospital and Health Sciences Centre, University of British Columbia, Canada.
We performed a double-blind, controlled trial to determine the optimal dose of intrathecal fentanyl in small-dose hypobaric lidocaine spinal anesthesia for outpatient laparoscopy. Sixty-four gynecological patients were randomized into three groups, receiving 0, 10, or 25 micrograms fentanyl added to 20 mg lidocaine and sterile water (total 3 mL). Administration was with 27-gauge Whitacre needles and patients sat upright until the block was > T-8. One patient in the 0-microgram fentanyl group required general anesthesia 40 min after the start of surgery, leaving 21 patients per group. Three patients in each of the 0-microgram and 10-microgram fentanyl groups had mild discomfort with trocar insertion, or return of some sensation and felt discomfort or sutures toward the end of surgery. Shoulder-tip pain was less frequent in the 25-microgram than 0-microgram fentanyl group, 28% vs 67% (P < 0.0166). Intraoperative supplementation with alfentanil (+/- propofol) was needed less often in the 25-microgram than 0-microgram fentanyl group, 43% vs 76% (P = 0.028). Recovery of sensation took longer in the 25-microgram than in the 0-microgram and 10-microgram fentanyl groups, 101 +/- 21 vs 84 +/- 20 and 87 +/- 18 min (P < 0.05), although motor recovery and discharge times were the same. Postoperative analgesia was needed earlier in the 0-microgram than in the 25-microgram fentanyl group, median 54 (13-120) vs 87 (65-132) min (P < 0.05). Pruritus was the only side effect that occurred more often in the 10-microgram and 25-microgram groups than in the 0-microgram fentanyl group, 62% and 67% vs 14% (P < 0.0166). One patient required an epidural blood patch for postdural puncture headache. Based on these results, we concluded that 25 micrograms intrathecal fentanyl is required when 20 mg lidocaine is used for hypobaric spinal anesthesia (SA) to ensure reliable, durable anesthesia, reduce shoulder-tip pain, and minimize the need for intraoperative supplementation. This dose provides longer postoperative analgesia and does not increase side effects apart from pruritus. SA with small-dose hypobaric lidocaine-fentanyl was found to be a satisfactory technique for outpatient laparoscopy, although postdural puncture headache can occur in some patients.
Urol Int 1996;57(2):80-84
Department of Surgery, National Yang-Ming University, School of Medicine, Veterans General Hospital, Taipei, Taiwan/ROC.
Feasibility and safety of laparoscopic ligation of bilateral internal spermatic varices under epidural anesthesia were assessed in 11 patients. Another 11 patients undergoing the same procedure under ventilation-assisted anesthesia served as controls. Patients in both groups belonged to the American Society of Anesthesia functional class I. Arterial blood analyses were obtained (1) in the horizontal supine position; (2) in the 15 degrees Trendelenburg position; (3) at 15 min after carbon dioxide pneumoperitoneum insufflation, and (4) at 15 min after desufflation in the supine position. In the epidural anesthesia group arterial blood parameters and respiratory rate remained stable in the Trendelenburg position. After intraperitoneal insufflation of carbon dioxide for 15 min, the arterial carbon dioxide level increased from 40.1 +/- 2.2 to 42.1 +/- 2.6 mm Hg, the respiratory rate increased from 17.0 +/- 1.4 to 20.6 +/- 1.2/min, the blood pH value decreased from 7.386 +/- 0.027 to 7.355 +/- 0.034, all values showing statistically significant differences. These changes returned to the preinsufflation level 15 min after release of the pneumoperitoneum. The above-mentioned parameters remained unchanged under the pneumoperitoneum by assisted ventilation in the control group. The mean time of surgery was similar in both groups: 82 and 90 min for the groups having general and epidural anesthesia, respectively. All laparoscopic procedures were accomplished successfully under general anesthesia. However, failure to ligate the internal spermatic varices occurred in 3 patients under epidural anesthesia, mainly due to patient intolerance to abdominal distension. The operation was continued under intubated general anesthesia for relaxing the abdominal muscle to provide an adequate working space. In 8 patients being successfully operated under epidural anesthesia, 5 experienced mild but tolerable abdominal distension; 2 complained of shoulder pain intraoperatively. Although laparoscopic ligation of internal spermatic varices could be accomplished in some patients under epidural anesthesia, it carried a high failure rate, more intraoperative morbidity, and significant arterial blood gas alterations. Routine ventilation-assisted anesthesia is suggested for therapeutic laparoscopy even for an easy procedure such as the ligation of the internal spermatic varices.
J Laparoendosc Surg 1994 Apr;4(2):117-120
Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee.
This study prospectively evaluated the efficacy of caudal epidural block in providing analgesia following inguinal herniorrhaphy and laparoscopy. Laparoscopy was used only to inspect the contralateral side to determine if a second hernia was present. No surgical manipulation was performed through the telescope. Following mask induction with halothane in nitrous oxide and oxygen, a caudal epidural block was performed with 1.2 mL/kg of 0.25% bupivacaine. Pain scores were obtained at four points during the in-hospital postoperative course, and the need for supplemental analgesic agents was assessed. A total of 45 patients were studied. Caudal epidural block could not be performed in 1 patient, and this patient was excluded from further consideration. There were 34 boys and 10 girls, ranging in age from 2 to 84 months (mean +/- SD 37.4 +/- 18.2 months) and weighing from 3.4 to 34 kg (mean +/- SD 14.2 +/- 5.8 kg). Thirty-six of 44 patients (82%) did not require supplemental analgesic agents during their in-hospital postoperative course and had pain scores of 2 or less at all four evaluation points. Six of 8 patients required a single dose of intravenous fentanyl (0.5 microgram/kg) to maintain scores of 2 or less. No significant complications related to caudal epidural block were noted in any patient. Caudal epidural block provides effective analgesia following inguinal herniorrhaphy and laparoscopy in children.
Anesth Analg 1992 Sep;75(3):381-385
Department of Anesthesiology, University of Amsterdam, The Netherlands.
Laparoscopic cholecystectomy (LPC) is increasingly used to treat symptomatic cholelithiasis. We compared the effects of cholecystectomy by subcostal incision to those of LPC on lung function and endocrine metabolic response. The effects of thoracic epidural analgesia for LPC were studied as well. Thirty patients undergoing elective cholecystectomy under general anesthesia were allocated to three study groups: group I, cholecystectomy by subcostal incision; group II, LPC; group III, LPC and epidural analgesia with 0.5% bupivacaine with epinephrine, followed by continuous epidural infusion of 6 mL of 0.5% bupivacaine. Forced vital capacity (FVC), peak expiratory flow, and forced expiratory volume in 1 s were measured with the patients in a half-sitting position. In all groups, sustained decreases in FVC, forced expiratory volume in 1 s, and peak expiratory flow were observed up to 24 h after surgery. Reduction of FVC was significantly more in group I compared with groups II and III (P less than 0.05). The FVC in group I decreased from 3.8 +/- 0.42 (SD) to 1.1 +/- 0.27 L (P less than 0.01), in group II from 3.6 +/- 1.46 to 2.1 +/- 0.94 L (P less than 0.05), and in group III from 3.8 +/- 0.92 to 2.8 +/- 0.90 L (P less than 0.05). In all groups, plasma glucose and cortisol increased after surgery compared with baseline levels (P less than 0.05). At 240 min after surgery, a small but significant decrease of cortisol was measured in group III (P less than 0.05).
Masui 1993 Jun;42(6):862-866
Department of Anesthesiology, Keio University, School of Medicine, Tokyo.
The present study was performed to clarify the influences of anesthetic methods and insufflating gases on arterial blood gas and ventilation during laparoscopy. Forty five women undergoing laparoscopy for gynecological procedure were studied after dividing into four groups; general anesthesia with control ventilation or epidural anesthesia with spontaneous breathing, plus insufflation with carbon dioxide (CO2) or nitrous oxide (N2O). After CO2 insufflation, PaCO2 increased significantly in the patients who were mechanically ventilated, but not in the patients breathing spontaneously. After N2O insufflation, the decrease in tidal volume (VT) and the increase in VD/VT were significant, but minute ventilation was well maintained by the compensatory increase in respiratory frequency during spontaneous breathing. On the other hand, after CO2 insufflation VE and VD/VT increased significantly without any change in VT. PaO2 decreased significantly after both insufflation and Trendelenburg tilt in all groups, probably secondary to the decrease in functional residual capacity. These findings suggest that during laparoscopy, ventilation could be well maintained by spontaneous breathing, although the increase in VD/VT and costal breathing indicate the increase in respiratory work load. We recommend that ventilation and oxygenation should be closely monitored during laparoscopy to avoid hypercapnia and hypoxia.
J Gynecol Obstet Biol Reprod (Paris) 1991;20(3):355-360
[Article in French]
Service de Gynecologie-Obstetrique, Hopital de la Pitie, Paris.
The authors used epidural anaesthesia to carry out laparoscopy in 220 patients. The chief indications for the laparoscopies were GIFT (intratubal transfer of gametes) and tubal sterilization. The technique used was slightly different according to the indications for the use but they had to be sure of anaesthetising up to T4. In 90% of cases the patients tolerated the procedure well. No change in ventilation or in metabolic measurements. As far as fertilization was concerned studies carried out in various parameters failed to show any untoward side effects due to the use of local anaesthetics. Finally so long as the anaesthesia is only used for a short length of time this technique seems to be suitable for day cases.
Anesth Analg 1990 Apr;70(4):357-361
Departement d'Anesthesie, Groupe Hospitalier Pitie-Salpetriere, Paris, France.
This study evaluates the respiratory effects of laparoscopy under epidural anesthesia in seven female patients (ASA physical status I) scheduled for a gamete intrafallopian transfer procedure. Epidural anesthesia was performed with 15-18 mL of 1.5% plain lidocaine using a catheter inserted at the L3-4 level. The upper level of analgesia to pinprick was measured 20 min after lidocaine injection. Ventilatory measurements and arterial blood gas analyses were performed (a) preoperatively, in the horizontal supine position with a T7-9 level of analgesia; (b) in the 20 degrees Trendelenburg position with a T2-5 level of analgesia; (c) during intraabdominal insufflation of CO2 through the laparoscope; and (d) after CO2 exsufflation by manual compression of the abdomen before removal of the laparoscope while in the horizontal position. On-line measurements of VO2, VCO2, VE, VT, F, and PETCO2 were made using a Beckman metabolic cart, while the patients breathed room air through an anesthetic face mask. No significant changes in the ventilatory variables were observed in the Trendelenburg position. In contrast, CO2 insufflation significantly increased VE (from 9.1 +/- 1.0 L/min to 11.8 +/- 2.6 L/min, mean +/- SD), and F (from 16.9 +/- 1.9 breaths/min to 23.1 +/- 3.3 breaths/min, mean +/- SD), whereas VCO2 remained unchanged. PaCO2 remained constant throughout the study. These results suggest that epidural anesthesia may be a safe alternative to general anesthesia for outpatient laparoscopy, as it is not associated with ventilatory depression.
Anaesthesia 1990 Mar;45(3):210-214
Department of Anesthesiology, University of Maryland Medical Center, Baltimore 21201.
The relationship between arterial carbon dioxide tension and end-tidal carbon dioxide tension was studied in 25 patients during laparoscopy. Thirteen patients received general anaesthesia and 12 epidural anaesthesia. The overall mean difference between arterial and end-tidal carbon dioxide tensions was 0.44 kPa (95% confidence intervals 0.28-0.60 kPa) which was significantly less than that reported in studies during other procedures. The reasons for this difference are probably associated with the physiological changes induced by CO2 pneumoperitoneum and steep Trendelenburg positioning. The choice of anaesthetic technique did not affect the arterial to end-tidal carbon dioxide tension difference significantly (p greater than 0.9).
J In Vitro Fert Embryo Transf 1987 Feb;4(1):23-29
Modifying effects of epidural analgesia and general anesthesia on stress hormone release was studied during laparoscopy for in vitro fertilization (IVF). In 24 women follicle development was stimulated by clomiphene and gonadotropin treatment, and oocytes were collected by laparoscopy under epidural analgesia in 11 women and under fentanyl-supplemented nitrous oxide-oxygen anesthesia in 13. The plasma levels of immunoreactive beta-endorphin (ir beta-E), cortisol, and prolactin (PRL) did not change under epidural analgesia per se, but after the start of laparoscopy, increased release of all these stress hormones was observed. General anesthesia per se increased the release of PRL, whereas the release of cortisol and ir beta-E decreased, probably due to the effects of fentanyl and thiopentone. During the stress attributed to laparoscopy, significantly more ir beta-E and cortisol was released under epidural than under general anesthesia, whereas the release of PRL was more significant under general anesthesia. These results show that neither mode of anesthesia prevented the stress response to laparoscopy. In the subsequent midluteal phase, the mean plasma level of progesterone and the mean progesterone-estradiol ratio were significantly greater in the epidural than in the general anesthesia group, suggesting that the mode of anesthesia may have an effect on the luteal phase. The significance of this difference on the conception rate remained unsolved, however.
Reg Anaesth 1987 Jan;10(1):16-23
[Article in German]
In a retrospective study clinical experience with epidural Bupivacaine 0.75% for laparoscopy is presented; the main interest of the study is focused on the relaxation of the abdominal wall musculature as expressed by compliance: volume of CO2-insufflation/pressure. Data of 55 patients were collected (= Group A) divided into 3 subgroups according to dosage: subgroup I = 15.0 ml = 112.5 mg (n = 12), II = 17.5 ml = 131.25 mg (n = 16), III = 20.0 ml = 150.0 mg (n = 27). These 55 patients are compared with two other groups of patients: group B = epidural anaesthesia with etidocaine 1.5% (n = 14) and group C = general anaesthesia with pancuronium as muscle relaxant 0.08 mg/kg (n = 7). Within group A the 3 subgroups do not show much difference except for one significant difference (p less than 0.05): between subgroup I and III concerning the upper limits of analgesia (1.5 segments: T 7 vs T 5/6), in the lowest dose-group the patients having the lowest weight (p less than 0.05). There was interdependence only with respect to two items: spread of analgesia (upper limit) depending on total dose (p less than 0.01) and on age (p less than 0.05), as well as dose/segment depending on age (p less than 0.01); despite statistical significance the correlation was rather weak.
J Reprod Med 1979 Aug;23(2):85-86
This study confirms that lumbar epidural block is a satisfactory anesthetic technique for outpatient laparoscopic tubal sterilization. Oxygenation during the period of pneumoperitoneum was adequate. The technique resulted in a shortened postanesthesia recovery period and fewer postanesthesia complications. Surgeon, anesthesiologist and patient acceptance was excellent.
Anesth Analg 1997 Jan;84(1):59-64
Department of Anaesthesia (Division of Ambulatory Anaesthesia, Vancouver Hospital and Health Sciences Centre, University of British Columbia, Canada. hvaghadi@vanhosp.bc.ca
A randomized, single-blind trial of two spinal anesthetic solutions for outpatient laparoscopy was conducted to compare intraoperative conditions and postoperative recovery. Thirty women (ASA physical status I and II) were assigned to one of two groups. Group I patients received a small-dose hypobaric solution of 1% lidocaine 25 mg made up to 3 mL by the addition of fentanyl 25 micrograms. Group II patients received a conventional-dose hyperbaric solution of 5% lidocaine 75 mg (in 7.5% dextrose) made up to 3 mL by the addition of 1.5 mL 10% dextrose. All patients received 500 mL of crystalloid preloading. Spinal anesthesia was performed at L2-3 or L3-4 with a 27-gauge Quincke point needle. Surgery commenced when the level of sensory anesthesia reached T-6. Intraoperative hypotension requiring treatment with ephedrine occurred in 54% of Group II patients but not in any Group I patients. Median (range) time for full motor recovery was 50 (0-95) min in Group I patients compared to 90 (50-120) min in Group II patients (P = 0.0005). Sensory recovery also occurred faster in Group I patients (100 +/- 22 min) compared with Group II patients (140 +/- 27 min, P = 0.0001). Postoperative headache occurred in 38% of all patients and 70% of these were postural in nature. Oral analgesia was the only treatment required. Spinal anesthesia did not result in a significant incidence of postoperative backache. On follow-up, 96% said they found spinal needle insertion acceptable, 93% found surgery comfortable, and 90% said they would request spinal anesthesia for laparoscopy in future. Overall, this study found spinal anesthesia for outpatient laparoscopy to have high patient acceptance and a comparable complication rate to other studies. The small-dose hypobaric lidocaine-fentanyl technique has advantages over conventional-dose hyperbaric lidocaine of no hypotension and faster recovery.
Fertil Steril 1993 Apr;59(4):841-843
Gundersen/Lutheran Medical Center, La Crosse, Wisconsin.
OBJECTIVE: To investigate the feasibility of performing GIFT under spinal anesthesia administered through a thin (27-gauge) needle. DESIGN: Prospectively studied case series. SETTING: A tertiary care center staffed by a 260 physician multispecialty group. PATIENTS: Twenty-seven consecutive fertility patients underwent 28 laparoscopic GIFT procedures, electing to receive spinal anesthesia administered through a thin (27-gauge) needle. INTERVENTIONS: Laparoscopic GIFT and thin-needle spinal anesthesia. MAIN OUTCOME MEASURES: Assessment of anesthetic complications and reproductive outcome. RESULTS: Satisfactory anesthesia was obtained in 27 of the 28 cases (96%). One patient required additional general anesthesia because of failed spinal anesthesia. All patients were discharged from the hospital on the day of surgery and no postdural headache, persistent back pain, meningitis, or neurological deficit was reported on a 7-day follow-up. Of the 12 clinical pregnancies (43%), 9 ongoing/delivered pregnancies occurred (32%). Six patients had livebirths, and three patients have ongoing second or third trimester pregnancies; there were three spontaneous abortions. CONCLUSIONS: Spinal anesthesia administered through a 27-gauge needle is an attractive option for laparoscopic GIFT. The risk of serious morbidity because of an anesthetic-related complications may be reduced, and the oocytes are not exposed to the potentially deleterious effects of the drugs associated with general anesthesia.
J Assist Reprod Genet 1995 Nov;12(10):678-682
Department of Obstetrics and Gynecology, Sapir Medical Center, Kfar, Saba, Israel.
OBJECTIVE: Our objective was to evaluate retrospectively the influence of different types of anesthesia on the outcome of ovum retrieval. METHODS: Sedation combined with local anesthesia was used on 120 occasions (Group I), epidural block in 139 ovum retrievals (Group II), and general anesthesia in 173 cycles (Group III). RESULTS: No differences were found in embryo yield or number or the quality of the embryo transferred. Of 99 pregnancies achieved, 66 live deliveries were recorded. Significantly lower clinical pregnancy rates were found in Group III (14.5%) compared with Group II (23.7%; P = 0.018) or Group I (25.8%; P = 0.0074). Highly significant differences were found in the delivery rates between Group III (8.7%), Group II (20.11%; P = 0.0017), and Group I (19.2%; P = 0.0043). CONCLUSION: The use of general anesthesia, especially nitrous oxide, for oocyte retrieval has an adverse effect on IVF outcome. This deleterious effect manifests itself only after embryo transfer and leads to lower pregnancy and delivery rates.