Can Epidural be an Alternative to General Anesthesia for Laparoscopic Hysterectomies?

BACKGROUND AND PURPOSE:

  • General anesthesia for laparoscopic surgery has multiple benefits, including pain control and a secure airway
  • Regional anesthesia also has benefits by addressing side effects posed by general anesthesia such as prolonged sedation and postoperative atelectasis
  • There is limited data on the use of regional anesthesia and hysterectomy
  • Moawad et al. (Obstetrics & Gynecology 2018) provide a case report of total lapraroscopic hysterectomy using epidural anesthesia without sedation

METHODS:

  • Case study
  • 51- year-old woman with abnormal uterine bleeding
  • Surgery: Laparoscopic hysterectomy, bilateral salpingectomy, and excision of endometriosis
  • Anesthesia: Epidural without IV sedation or systemic narcotics
    • Midthoracic and low lumbar epidural catheters dosed with ropivacaine 0.5%, (total of 6 mL lumbar and 4 mL through midthoracic) followed by 0.2% infusions
    • Bilevel positive airway pressure was used for augmentation of respiratory function
  • Bupivacaine injected at the primary trocar site
  • Right intra-procedure shoulder pain managed with
    • Spraying of the right diaphragmatic cupola with 10 mL of 0.25% bupivacaine
    • 100 micrograms of fentanyl through the thoracic epidural
  • Pneumoperitoneum achieved with a pressure of 12 mm Hg and Trendelenburg to 10-15° allowed for adequate visualization
  • Multiport laparoscopic hysterectomy procedure
    • Three 5-mm secondary trocars in the bilateral lower quadrants and suprapubic area
  • 14 week size uterus removed using anterior approach for uterine artery ligation due to poor posterior cul de sac access

RESULTS:

  • The surgery was completed successfully
  • No IV narcotics nor anxiolytics were required

CONCLUSION:

  • For select women, epidural anesthesia is a viable option when undergoing a laparoscopic hysterectomy
  • Authors suggest
    • Limiting Trendelenburg to minimum required for visualization and bowel retraction
    • Use low CO2 flow and pressure to reduce shoulder pain
  • Authors attribute their success to

“adequate preoperative counseling, our patient’s commitment, the application of scientific evidence, and the intense collaboration between the surgical and anesthesia teams.”

Learn More – Primary Sources:

Total Laparoscopic Hysterectomy Under Regional Anesthesia