laproscopic cholecystectomy under segmental spinal anesthesia

Started by dramitshah, July 10, 2007, 12:12:11 PM

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dramitshah

there was one study on laproscopic cholecystectomy done under segmental spinal anesthesia with injection of 1 ml of bupivacaine heavy at T10 level  at anesthesia now.com.

any one has conducted lap cholecystectomy by this method?
if yes than what was your experience.
what about co2 washout.
was ET CO2 monitored ? and if yes what was the result?

please share your thoughts as literature has little to offer and surgeons are pressing for regional anesthesia for the laproscopic surgery.
i am anesthesiologist from vadodara, gujarat, India

jafo1964

we attempted a study on SAB for lower abdominal laproscopic surgeries.
Surgeries included were lap appendicectomy, lap hernia and lap varicocoelectomy
we ensured neutral position only and kept intra-abdominal pressures limited to 12mmHg.
SAB level was T4 - T5. Sedation included Midazolam 50mcg/kg and ketamine 0.5mg/kg

We had to abandon study  since all patients needed conversion to GA except one who was managed with unacceptably high doses of ketamine.

Primary complaint was severe pain in shoulder area and some patients expressed discomfort during breathing although SaO2 and ETCO2 were within acceptable limits.

Although there is plenty of literature our experience did not support the findings

amarkatira

we have done a few cases of lower abdomen laproscopies but they all needed little ketamin or propofol.

yogenbhatt1

Hi, Amit, I have conducted Lap choles under Spinal/ Epidural. Well, as you read even our senior colleague Jafo1964, true name not known, I was also not happy with the technique. Some recommend sprey of Xylocain on Diaphram, but I was not happy with that too. Actually when patient is uncomfortable and in pain we take it as a defeat, and also surgeon also is not happy. I have also given up.
but , lower abdomenal and pelvic surgeries, we were quite happy. We use to think that sedation will reduce respiratory efforts or volume, but the capno gram and SpO2 were very steady. There was no hypertension and no tachycardia.
Well, We have stopped breaking our head with that too. We are back to standard GA.
I have even come to believe that tachy and hypertension and raised ETCO2 are due to pain from improper analgesics, which increase stress.
I know that is will give me lots of corrections, because it is a belief and not a study.

frontier

hi, can be done under regional anaesthesia or local anaesthesia.biggest disadvantage patient goes for hyperventilation to combat hypercarbia leading to excessive movements in the sugical field hampering surgery.2nd disadvantage hypoxemia due to trendelenberg position & reducedFRC.at the same time reduced cardiac output due to sympathetic blockade caused by regional anaesthesia.should go for regional or local anaesthesia only if patient not fit for GA.WITH REGARDS.

jafo1964

In response to Dr.yogens observations

Hypertension and tachycardia usually occurs soon after inflation because the acute increase in Intra-abdominal pressures produces a great increase in catecholamines thus producing these effects.  I normally dont try to treat these increases unless they really go out of hand in a patient with risk of target organ damage

Most of the time we tend to hyperventilate our patients so hypercarbia is an extremely rare occurence unless there is some other major problem. Infact we see mostly hypocarbia and normocarbia all the time.
Hypercarbia due to absorption of CO2 from peritoneal absorption is most common to occur 30 to 45 minutes post -operatively and to be honest at that point of time none of us are looking at ETCO2.

edelcar

We use epidural anaesthesia (T7-T8) for chole-lap, to avoid the omalgia -shoulder pain- we spray the diaphragm with lidocaine 2% without epinephrine (5cc + SF 15 cc). Patients don't have pain and there are not changes in AGA and their hemodinamic state are good; they compensate the hipercarbia with light increase in the respiratory rate. Our experiency is very good and the patients are satisfy.