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