Extraperitoneal endoscopic groin hernia repair under epidural anesthesia

Spinal versus general anesthesia for transabdominal preperitoneal (TAPP) repair of inguinal hernia: Interim analysis of a controlled randomized trial

BACKGROUND

General anesthesia has been used as standard for laparoscopic hernia repair by the transabdominal preperitoneal (TAPP) approach. Regional anesthesia has been occasionally applied in high risk patients where general anesthesia is contraindicated. This randomized clinical trial compares spinal anesthesia with general anesthesia for TAPP inguinal hernia repair in non-high risk patients.

METHODS

Seventy adult American Society of Anesthesiologists I, II and III patients undergoing elective TAPP inguinal hernia repair were randomized to either general or spinal anesthesia.

RESULTS

Postoperative morphine consumption was significantly less immediately postoperatively (p < 0.001) in the spinal anesthesia group. Postoperative pain was also significantly decreased within the first 8 h postoperatively (p < 0.05) in the spinal anesthesia group.

CONCLUSIONS

Spinal anesthesia offers some advantages in patient analgesia during the early postoperative period after TAPP inguinal hernia repair and can be proposed as an effective alternative method of anesthesia for TAPP repair.

Major laparoscopic surgery under regional anesthesia: A prospective feasibility study

BACKGROUND

Laparoscopic surgeries have attained the status of a gold standard for most of the abdominal pathology; we therefore performed this study to assess feasibility and safety of major laparoscopic surgeries like laparoscopic cholecystectomy (LC) and laparoscopic assisted vaginal hysterectomy (LAVH)/total laparoscopic hysterectomy (TLH) under regional anesthesia that is combined spinal epidural anesthesia (CSE) with normal pressure pneumoperitoneum using intrathecal fentanyl with bupivacain.

METHODS

In a zonal government hospital, 50 patients were selected prospectively for LC and LAVH/TLH, under normal pressure (12 mmHg) pneumoperitoneum and under CSE over a span of fifteen months. Injection bupivacaine (0.5%) and 20 μg of fentanyl were used for spinal anesthesia. Plain bupivacaine (0.5%) was used for epidural anesthesia.

RESULTS

We successfully performed the operations in 48 patients without major complications. CSE was converted to general anesthesia in two patients due to distressing shoulder tip pain. Age varied between 25 and 70 years. Duration of operation time (skin to skin) was between 50 and 170 min. Five patients had urinary retention and one developed localized pruritis. There was no incidence of respiratory depression, aspiration or headache.

CONCLUSION

Laparoscopic surgeries with normal pressure CO2 pneumoperitoneum are feasible and safe under CSE. Incidence of postoperative shoulder pain was minimal due to use of intrathecal fentanyl and complications were less and easily manageable.

Combined spinal epidural anesthesia for laparoscopic appendectomy in adults: A case series

Background:

Laparoscopy is one of the most common surgical procedures and is the procedure of choice for most of the elective abdominal surgeries performed preferably under endotracheal general anesthesia. Technical advances in the field of laparoscopy have helped to reduce surgical trauma and discomfort, reduce anesthetic requirement resulting in shortened hospital stay. Recently, regional anaesthetic techniques have been found beneficial, especially in patients at a high risk to receive general anesthesia. Herewith we present a case series of laparoscopic appendectomy in eight American Society of Anaesthesiologists (ASA) I and II patients performed under spinal-epidural anaesthesia.

Methods:

Eight ASA Grade I and II adult patients undergoing elective Laparoscopic appendectomy received Combined Spinal Epidural Anaesthesia. Spinal Anaesthesia was performed at L₂-L₃ interspace using 2 ml of 0.5% (10 mg) hyperbaric Bupivacaine mixed with 0.5ml (25 micrograms) of Fentanyl. Epidural catheter was inserted at T₁₀-T₁₁ interspace for inadequate spinal anaesthesia and postoperative pain relief. Perioperative events and operative difficulty were studied. Systemic drugs were administered if patients complained of shoulder pain, abdominal discomfort, nausea or hypotension.

Results:

Spinal anaesthesia was adequate for surgery with no operative difficulty in all the patients. Intraoperatively, two patients experienced right shoulder pain and received Fentanyl, one patient was given Midazolam for anxiety and two were given Ephedrine for hypotension. The postoperative period was uneventful.

Conclusion:

Spinal anaesthesia with Hyperbaric Bupivacaine and Fentanyl is adequate and safe for elective laparoscopic appendectomy in healthy patients but careful evaluation of the method is needed particularly in compromised cardio respiratory conditions.

Comparative study of the changes in partial pressure of plasma carbon dioxide during carbon dioxide insufflation into the intraperitoneal and preperitoneal spaces

BACKGROUND

We aimed to compare plasma concentrations of carbon dioxide (CO(2)) in dogs that underwent intra- and preperitoneal CO(2) insufflation.

MATERIALS AND METHODS

Thirty dogs were studied. Ten formed a control group, 10 underwent intraperitoneal CO(2) insufflation, and 10 underwent preperitoneal CO(2) insufflation. General anesthesia with controlled ventilation was standardized for all dogs. After stabilizing the anesthesia, blood samples were collected at predetermined times and were sent for immediate gasometric analysis. Analysis of variance was used for comparing variables.

RESULTS

The plasma CO(2) concentration in the intraperitoneal insufflation group increased significantly more than in the preperitoneal insufflation group and was significantly greater than in the control group (P < 0.05). The pH values in the intraperitoneal group were lower than in the preperitoneal group (P < 0.05).

CONCLUSION

The data from this study suggest that a greater plasma concentration of CO(2) is achieved by insufflation at constant pressure into the intraperitoneal space than into the preperitoneal space.

Laparoscopic total extraperitoneal inguinal hernia repair under spinal anesthesia: a study of 480 patients

OBJECTIVES

Laparoscopic total extraperitoneal inguinal hernia repair (TEP) is conventionally performed under general anesthesia (GA), and regional anesthesia is usually preferred in patients where GA is contraindicated. In this paper, we present our experience of over 8 years of using spinal anesthesia (SA) as the first choice with the contention that it is a better alternative to GA.

METHODS

SA was used in 480 patients over the last 8 years, and 464 patients underwent unilateral TEP. Strangulated and obstructed hernia patients were excluded, but irreducible hernia patients were included. Sedation was given if required, and the conversion to GA was done in patients not responding to sedation or with failure of SA. Comparative control included TEP performed under GA in our initial 49 patients.

RESULTS

Three (0.63%) patients required a conversion to GA. Hypotension requiring support was recorded in 75 (15.63%) patients. Postoperatively, 2.08% (10) patients had vomiting, as compared to 30.61% (15 patients) in patients administered GA. In all, 35.83% (172) of patients required injectable diclofenac for their abdominal pain within 2 hours postoperatively, and oral analgesic was required in 301 (62.71%) patients within the first 24 hours, while 89.80% (44) patients operated an under GA required injectable analgesics in the immediate postoperative period and subsequent oral analgesia request was the same as in patients with SA. Postural headache, persisting for an average of 2.6 days, was seen in 25 (5.21%) patients postoperatively. Average time to discharge was 2.3 days. Kernofsky's performance status showed a 98.6% satisfaction level in patients.

CONCLUSIONS

TEP done under SA has a number of advantages over GA and should be used routinely.

Laparoscopic inguinal total extraperitoneal hernia repair under spinal anesthesia without mesh fixation in 1,220 hernia repairs

BACKGROUND

The need for general anesthesia and the cost and pain due to metal staples required for fixing the mesh are the major reported disadvantages of laparoscopic total extraperitoneal (TEP) hernia repair. We studied the feasibility and results of TEP done under spinal anesthesia with non-fixation of the mesh (SA-NF). This group was compared to TEP done under general anesthesia with non-fixation of the mesh (GA-NF) and repairs done under SA with fixation of the mesh (SA-F).

METHODS

A retrospective analysis was carried out in 675 patients (1,289 hernias) in whom TEP was performed. The recurrence rate, pain scores at 24 h and 1 week, hospital stay, days to resume normal activities, seroma formation, and urinary retention rates were noted.

RESULTS

A total of 1,289 TEP repairs (675 patients) were analyzed, with 636 patients (1,220 hernias) in the SA-NF group, 16 patients (27 hernias) in the GA-NF group, and 23 patients (42 hernias) in the SA-F group. Follow up ranged from 13 to 45 months. The recurrence rates, conversion rates, and complications were similar in all three groups. The mean hospital stay, days to resume normal activities, and pain scores were significantly higher in the mesh fixation (SA-F) group.

CONCLUSIONS

TEP, done under SA and without fixation of the mesh, is safe, feasible, and associated with low recurrence rates. Since this procedure does not have the disadvantages usually attributed to TEP, it can be possibly recommended as a first-line procedure, even for unilateral inguinal hernias. Further studies are needed to substantiate this.

Endoscopic Totally Extraperitoneal Inguinal Hernioplasty Under Spinal Anesthesia

OBJECTIVES

Although endoscopic totally extraperitoneal inguinal hernioplasty (TEP) confers superior early outcomes compared to those of open repair, the requirement of general anesthesia has been held as an argument against the application of TEP by opponents of laparoscopic surgery. To date, the literature on TEP performed under spinal anesthesia remains scarce. The present study reports our early experience performing TEP under spinal anesthesia in selected patients who were medically unfit for general anesthesia.

METHODS

Between March 2003 and March 2004, 6 male patients underwent attempted TEP under spinal anesthesia. Selection criteria for the procedure included reducibility of the inguinal hernia and concomitant medical conditions precluding general aesthesia, such as impaired lung function. Informed consent was obtained in all patients.

RESULTS

All patients were conscious and able to communicate verbally during the operation. TEP was successfully completed in 4 patients, with a mean operative time of 33 minutes. All 4 patients were asymptomatic and experienced no pain throughout the procedure. Conversion to open repair was required in 2 patients because of uncooperative movement in one, and inadequate neural blockade by spinal anesthesia in the other. Intraoperative cardiorespiratory parameters were stable in all patients. Postoperative urinary retention occurred in 1 patient. The mean length of follow-up exceeded 3 months, and no seroma or recurrence was detected clinically.

CONCLUSION

Successful performance of TEP under spinal anesthesia requires the combined efforts of an experienced anesthesiologist, a skilled surgeon, and a cooperative patient. Our initial experience of TEP under spinal anesthesia appeared promising. TEP under spinal anesthesia may have a role in selected patients who are medically unfit for general anesthesia but are otherwise suitable for TEP.

[Surgery of inguinal hernia as ambulatory and brief inpatient surgery]

Ambulatory surgery of inguinal hernia is gaining in popularity. While in the USA, admitting patients for inguinal hernia surgery is an exception, fewer than 10% of all such operations in Germany are performed in a day-case surgical setting. One reason for the situation observed in Germany is still a lack of acceptance by the patients. A second reason is the general nature of our health system. Surgery of the inguinal hernia can adequately be done as a standardised ambulatory procedure. We prefer conventional repair under local anaesthesia. In qualified hands, vitally dangerous complications are minimal. Careful indication, standardisation of the procedure as well as good information for and guidance of the patients provide a basis for successful day-case surgery. Indications, limitations, and risks are presented and analysed from a clinical point of view.