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