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

Transvaginal vs Laparoscopic Cuff Closure to Prevent Dehiscence

BACKGROUND AND PURPOSE:

• Vaginal cuff dehiscence is estimated to be between 0.1-0.2% following open or vaginal hysterectomy
• Some reports have suggested that minimally invasive procedures may result in increased risk for dehiscence
• Previous literature has reported that a transvaginal approach to vaginal cuff closure at the end of an otherwise totally endoscopic hysterectomy reduces the risk of postoperative vaginal breakdown
• Uccella et al. (AJOG, 2018) undertook an RCT to compare laparoscopic vs TV closure of the vaginal vault following laparoscopic hysterectomy

METHODS:

• Multicentered randomized study
• Participants: Patients undergoing total laparoscopic hysterectomy for benign indications
• Patients received vaginal closure through either:
  • Transvaginal approach
    • Vaginal closures had a single-layer running braided and coated 0-polyglactic suture
  • Laparoscopic approach
• Monopolar energy for colpotomy was set at 60W
• In all cases an attempt was performed to include the posterior peritoneum in the suture
• Laparoscopic knots were tied intracorporeally
• 3 month follow up to identify possible vaginal cuff complications
• Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after total laparoscopic hysterectomy
• Primary outcome
  • Rate of vaginal cuff dehiscence
  • Secondary outcomes were
    • Vaginal bleeding, vaginal cuff hematoma, postoperative infection, vaginal resuturing, any reoperation, and a combined outcome defined as “any cuff complication,” including any patient with at least 1 vaginal dehiscence, vaginal hematoma, vaginal bleeding, postoperative infection, or vaginal resuturing

RESULTS:

• Study was stopped early following interim analysis
• 1,408 patients were enrolled in a prespecified interim analysis
  • 13 (0.9%) women did not undergo the postoperative assessment and were excluded
• Baseline characteristics of the 1395 patients included (695 in the transvaginal group and 700 in the laparoscopic group) were similar
• Patients in the transvaginal group had significantly higher rates of the following
  • Vaginal dehiscence: 2.7% vs 1%; odds ratio (OR) 2.78; 95% CI, 1.16–6.63 (P=.01)
  • Cuff complications: 9.8% vs 4.7%; OR 2.19; 95% CI, 1.43–3.37 (P=.0003)
• After multivariable analysis, transvaginal closure of the vault was independently associated with higher rates of vaginal dehiscence and vaginal complications
• Higher risk of dehiscence was also associated with premenopausal status and smoking habit

CONCLUSION:

• Laparoscopic closure is associated with reduced risk for vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal resuture, and reintervention
• Possible explanations for laparoscopic closure being a superior approach are
  • Performing the suture intraabdominally allows the surgeon to incorporate the peritoneum
  • Closing the gap between the vaginal mucosa and the pouch of Douglas may decrease postoperative oozing reducing hematoma risk
  • Magnification capability using laparoscopy

Learn More – Primary Sources:

Laparoscopic vs transvaginal cuff closure after total laparoscopic hysterectomy: a randomized trial by the Italian Society of Gynecologic Endoscopy