Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 9  |  Issue : 4  |  Page : 620-622

Case report and review of the literature. Novel anesthetic technique in laparoscopic myomectomy


1 Anaesthesia Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2 Internal Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission31-Oct-2015
Date of Acceptance22-Apr-2016
Date of Web Publication12-Jan-2017

Correspondence Address:
Megahed M El Fattah
Anaesthesia department, Faculty of Medicine, Ain Shams University, Cairo 1226
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.198255

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  Abstract 

Thoracic epidural anesthesia for elective laparoscopic myomectomy is a good alternative to general anesthesia and seems to be an effective technique, with minimal hemodynamic consequences and excellent patient satisfaction and no postoperative complications (provided the patient cooperated), minimal inflation pressure, and mild table tilt. We present here one case of laparoscopic myomectomy under thoracic epidural anesthesia in a patient with relative contraindication to general anesthesia.

Keywords: laparoscopic myomectomy, laparoscopic surgery, neuraxial block, thoracic epidural anesthesia


How to cite this article:
El Fattah MM, Gamie SA. Case report and review of the literature. Novel anesthetic technique in laparoscopic myomectomy. Ain-Shams J Anaesthesiol 2016;9:620-2

How to cite this URL:
El Fattah MM, Gamie SA. Case report and review of the literature. Novel anesthetic technique in laparoscopic myomectomy. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2017 Oct 22];9:620-2. Available from: http://www.asja.eg.net/text.asp?2016/9/4/620/198255


  Introduction Top


Laparoscopic cholecystectomy with pneumoperitoneum has traditionally been performed under general anesthesia. However, owing in part to the advancement of surgical and anesthetic techniques, many laparoscopic surgeries have been successfully performed under the spinal anesthetic techniques [1],[2],[3]. In recent years, advanced laparoscopic surgery has targeted older and high-risk sick patients for general anesthesia. In these patients, regional anesthesia offers several advantages with improved patient satisfaction. Generally, spinal anesthesia has lower postoperative mortality and fewer complications compared with general anesthesia, and hence spinal anesthesia seems more suitable for the minimally invasive laparoscopic surgery [4]. Thoracic epidural anesthesia provides a segmental, temporary motor and sensory block that has advantages over lumbar spinal anesthesia, such as reducing morbidity and mortality by reducing cardiac and splanchnic sympathetic activity [5]. In addition, the level of anesthesia achieved with a spinal anesthetic is too low to perform laparoscopic surgery in some cases, due to pooling of drug in the sacral region by lumbar lordosis [6]. Although further evaluation and comparison will be required, segmental thoracic epidural anesthesia in laparoscopic surgery offers some benefits over lumbar spinal anesthesia: the avoidance of urinary retention and the benefit of a daytime surgery setting [7].

However, this anesthetic approach requires a relaxed and cooperative patient, low intra-abdominal pressure to reduce shoulder pain, postoperative nausea, vomiting, and ventilatory disturbances, and reduced table tilt with a precise and gentle surgical technique [7].


  Case report Top


A 34-year-old female patient of American Society of Anesthesiologists class II presented with large uterine intramural leiomyoma with past history of subarachnoid hemorrhage managed medically in March 2014 at our hospital, Saudi German Hospital Dubai, with no neurological consequences.

Neurological consultation was asked from the same treating physician, and he recommended regional anesthesia as the optimum method of choice for the patient.

After obtaining informed written approval and high-risk consent from the patient, with normal partial thrombin time, porthrombin time, and international normalized ratio, she was scheduled to undergo laparoscopic myomectomy. The patient was informed about the advantages and disadvantages of epidural anesthesia and possible conversion to general anesthesia; similarly, the surgeon was prepared for conversion to open procedure, if required.

On the patient’s arrival at the operating room, noninvasive monitoring (ECG, noninvasive blood pressure monitoring, and pulse oximetry) and a peripheral venous infusion of 20 ml/kg lactated Ringer to prevent hypotension during anesthetic procedure were started 20 min before anesthesia. Oxygen 3 l/min was applied through a nasal cannula.

The patient was placed in sitting position; under full aseptic precautions, local infiltration of the skin and needle trajectory down to the ligamentum flavum was administered with xylocaine 1% at the desired level (T9–T10). An epidural block catheter (Perifix; B. Braun, Melsungen, Germany) was placed at the 10th thoracic interspace using a 17-G Tuohy needle and a paramedian approach. The epidural space was identified by the loss of resistance technique and the tip of the catheter was advanced 5 cm cephalad beyond the tip of needle. The anesthetic solution was prepared with xylocaine 2% plus epinephrine (1 : 200 000).

After 2 min, when there was no evidence of intravascular or subarachnoid injection, 8 ml of bupivacaine 0.5% was injected over 5 min period with 100 μg of fentanyl, and an additional 2 ml of the solution was administered incrementally to reach the desired level of segmental block. Upper and lower levels of sensory and motor block were assessed using the pinprick test and the Bromage scale, respectively. After confirmation of adequate level of anesthesia (T4–T12), 10 mm umbilical portal entry and pneumoperitonium were created at 7 mmHg and maintained at 8 mmHg inflation pressure; two inguinal 5 mm and one suprapubic 5 mm ancillary ports were applied. With mild degree of table tilt, myomectomy was performed smoothly and the patient was hemodynamically stable and awake throughout the procedure.

Intraoperative anxiety was treated with midazolam 1–2 mg, and hypotension with ephedrine 5–10 mg, all in the form of intravenous boluses as required.

The average duration of the surgery was 2 h and the procedure went smoothly with no complications.


  Discussion Top


Epidural anesthesia was considered relatively safe for laparoscopic cholecystectomy without associated respiratory depression, as the respiratory control mechanism needs to remain intact to allow the patients to adjust their minute ventilation. Moreover, the respiratory changes are less evident in awake patients under regional anesthesia and patients maintain an unchanged end-tidal carbon dioxide [8]. The central neuraxial anesthesia has been found beneficial usually in patients with significant medical diseases when low intra-abdominal pressure and less degree of patient tilt during surgical procedure is used [5]. The shoulder pain, secondary to diaphragmatic irritation from carbon dioxide pneumoperitoneum, is incompletely alleviated using epidural anesthesia alone, and extensive sensory block from T4 to L5 is needed for the laparoscopic procedure. Many researchers have observed that laparoscopic cholecystectomy performed under regional analgesia is advantageous due to reduction of surgical stress response, avoidance of airway instrumentation, and lower incidence of deep vein thrombosis.

Van Zundert et al. [2] noted shoulder and neck pain in two of their six patients operated under epidural anesthesia. Minai et al [9]. attributed the high incidence of shoulder pain to the physical and chemical stimulation of the diaphragm by pneumoperitoneum. In our case, there was no shoulder pain observed, which could be attributed to low intra-abdominal pressure of 8 mmHg combined with minimal table tilt. At intra-abdominal pressure less than 15 mmHg, venous return is augmented as blood is squeezed out of splanchnic venous bed with increased cardiac output, which also increased secondary to peripheral vasoconstriction due to hypercapnia [10]. In our case, the hemodynamic changes were also minimal due to preloading with 20 ml/kg of Ringer lactate over 20 min, low intra-abdominal pressure, and minimal table tilt. There was no postoperative nausea and vomiting reported, which could be attributed to antiemetic prophylaxis with multimodal treatment of patients with high risk for postoperative nausea and vomiting, avoidance of hypotension, adequate pain control, and avoidance of postoperative parenteral opioid medications.

On this basis and after review of the literature, this case report was aimed to evaluate the efficacy of epidural anesthesia for laparoscopic myomectomy as a part of ongoing large randomized clinical study on the safety of thoracic epidural anesthesia for high-risk surgical cases. Lack of complications and morbidity in previous research studies encourage us to share our experience of thoracic epidural anesthesia for laparoscopic myomectomy.

At the time of discharge of this case, the patient was satisfied with the anesthetic technique, good postoperative pain control and minimal nausea and vomiting. Bejarano González-Serna et al. [11] used spinal anesthesia with midazolam sedation for laparoscopic ventral hernia repair and concluded that spinal anesthesia is feasible and well tolerated. Van Zundert et al. [2] stated that segmental spinal anesthesia can be used safely for patients with impaired organ function. Lau et al. [12] also quoted that laparoscopic hernia can be performed successfully under spinal anesthesia. However, epidural anesthesia is not free from complications, dural puncture, and sympathetic denervation of high regional block, which may lead to bradycardia, hypotension, and decreased cardiac output. The vigilant monitoring and of course high technical skill of the anesthesiologist needed to perform thoracic epidural safely are essential for the prevention and treatment of complications.

In this case report, our results are related to many factors: we used a low CO2 pressure of 8 mmHg, our surgeon was experienced, and operative time was relatively short.


  Conclusion Top


This case report has demonstrated that laparoscopic myomectomy and postoperative analgesia are feasible under thoracic epidural anesthesia. This approach should be considered as a valid option for patients with multiple fibroids who are poor candidates for general anesthesia due to cardiopulmonary problems as well as for patients with other contraindications for general anesthesia.

Thoracic epidural anesthesia for elective laparoscopic myomectomy seems to be an effective technique, with minimal hemodynamic consequences and excellent patient satisfaction and no postoperative complications in the form of pain, nausea, or vomiting (provided the patient cooperated), minimal inflation pressure, and mild table tilt.

Further studies on large scale is recommended to evaluate the efficacy and safety of this technique to be conducted in high-risk surgical patients. Close monitoring and follow-up are crucial to ensure patient safety with thoracic epidural anesthesia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Tzovaras G, Fafoulakis F, Pratsas K, Georgopoulou S, Stamatiou G, Hatzitheofilou C. Laparoscopic cholecystectomy under spinal anesthesia: a pilot study. Surg Endosc 2006;20:580–582.  Back to cited text no. 1
    
2.
Van Zundert AA, Stultiens G, Jakimowicz JJ, Peek D, van der Ham WG, Korsten HH, Wildsmith JA Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007;98:682–686.  Back to cited text no. 2
    
3.
Yuksek YN, Akat AZ, Gozalan U, Daglar G, Pala Y, Canturk M et al. Laparoscopic cholecystectomy under spinal anesthesia. Am J Surg 2008;195:533–536.  Back to cited text no. 3
    
4.
Hamad MA, El-Khattary OA. Laparoscopic cholecystectomy under spinal anesthesia with nitrous oxide pneumoperitoneum: a feasibility study. Surg Endosc 2003;17:1426–1428.  Back to cited text no. 4
    
5.
Beattie WS, Badner NH, Choi P. Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesth Analg 2001;93:853–858.  Back to cited text no. 5
    
6.
Kim JT, Shim JK, Kim SH, Jung CW, Bahk JH. Trendelenburg position with hip flexion as a rescue strategy to increase spinal anaesthetic level after spinal block. Br J Anaesth 2007;98:396–400.  Back to cited text no. 6
    
7.
Tzovaras G, Pratsas K, Georgopoulou S. Laparoscopic cholecystectomy using spinal anesthesia. Br J Anaesth 2007; 99:744. author reply 745  Back to cited text no. 7
    
8.
Raju NP, Sivasashanmugam T, Ravishankar M. Respiratory changes during spinal anesthesia for gynacological laparoscopic surgery. J Anaesth Clin Pharmacol 2010;26:475–479.  Back to cited text no. 8
    
9.
Minai H, Yamada K, Tashiro K, Yamamoto K. Anesthetic management for awake laparoscopic surgery for ectopic pregnancy in a patient with heterotopic pregnancy. Masui 2005;54:1313–1314.  Back to cited text no. 9
    
10.
Odeberg S, Ljungqvist O, Svenberg T, Gannedahl P, Bäckdahl M, von Rosen A, Sollevi A Haemodynamic effects of pneumoperitoneum and the influence of posture during anaesthesia for laparoscopic surgery. Acta Anaesthesiol Scand 1994;38:276–283.  Back to cited text no. 10
    
11.
Bejarano González-Serna D, Utrera A, Gallego JI, Rodríguez R, De la Portilla F, Espinosa JE, Gil M. Laparoscopic treatment of ventral hernia under spinal anesthesia. Cir Esp 2006;80:168–170.  Back to cited text no. 11
    
12.
Lau H, Wong C, Chu K, Patil NG. Endoscopic totally extraperitoneal inguinal hernioplasty under spinal anesthesia. J Laparoendosc Adv Surg Tech A 2005;15:121–124.  Back to cited text no. 12
    




 

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