European Journal of Cardiovascular Medicine

Gynecological surgeries, both open and minimally invasive, are commonly performed procedures in women of reproductive and perimenopausal age groups for conditions such as fibroids, abnormal uterine bleeding, endometriosis, and malignancies. These surgeries are associated with varying degrees of tissue trauma, necessitating effective anesthetic strategies to ensure patient safety, hemodynamic stability, and adequate pain control during and after the procedure (1).

The choice of anesthesia plays a crucial role in influencing perioperative outcomes, including intraoperative complications, postoperative pain scores, recovery times, and patient satisfaction. General anesthesia (GA) remains a widely utilized technique due to its rapid induction and ease of control, especially in laparoscopic and lengthy surgeries (2). However, it may be associated with adverse effects such as postoperative nausea and vomiting, respiratory depression, and hemodynamic variability (3). Regional anesthesia (RA), including spinal or epidural blocks, is increasingly favored for certain gynecologic procedures due to its efficacy in providing targeted pain relief and improved postoperative recovery (4).

An alternative gaining prominence is the combined spinal-epidural (CSE) technique, which integrates the benefits of both spinal and epidural anesthesia. This technique allows for a rapid onset of anesthesia with prolonged postoperative analgesia, thereby improving patient comfort and reducing the need for systemic analgesics (5). The comparative effectiveness of these anesthetic techniques in terms of postoperative pain management, surgical duration, and complication profiles in invasive gynecological procedures remains inadequately explored in large-scale clinical studies.

This study aims to evaluate and compare the intraoperative and postoperative outcomes of general anesthesia, regional anesthesia, and combined spinal-epidural anesthesia in women undergoing invasive gynecological surgeries.

A total of 90 female patients, aged 30 to 60 years, scheduled for elective invasive gynecological surgeries (including abdominal hysterectomy and laparoscopic myomectomy), were enrolled after obtaining written informed consent. Inclusion criteria included.

American Society of Anesthesiologists (ASA) physical status I or II and absence of known contraindications to regional or general anesthesia. Patients with coagulation disorders, neurological diseases, or those on chronic analgesic therapy were excluded.

Grouping and Anesthesia Protocol
Patients were randomly assigned into three equal groups (n = 30 each) based on the anesthetic technique:

• Group A (General Anesthesia - GA): Patients received intravenous induction with propofol (2 mg/kg), fentanyl (2 µg/kg), and vecuronium (0.1 mg/kg) for muscle relaxation. Anesthesia was maintained with sevoflurane and intermittent doses of vecuronium.
• Group B (Spinal Anesthesia - RA): Patients received a subarachnoid block with 3 ml of 0.5% hyperbaric bupivacaine using a 25G Quincke needle at the L3–L4 interspace under aseptic precautions.
• Group C (Combined Spinal-Epidural - CSE): A combined technique was employed using a CSE kit. The spinal component consisted of 2 ml of 0.5% hyperbaric bupivacaine, followed by placement of an epidural catheter for postoperative analgesia using 0.125% bupivacaine infusion at 5 ml/hr.

Outcome Measures
Primary outcomes included:

• Intraoperative hemodynamic stability (measured via systolic and diastolic blood pressure and heart rate).
• Postoperative pain scores assessed using the Visual Analog Scale (VAS) at 2, 6, and 24 hours.

Secondary outcomes included:

• Total duration of surgery.
• Incidence of postoperative nausea and vomiting (PONV).
• Requirement for rescue analgesia.

Data Collection and Statistical Analysis
Hemodynamic parameters were recorded at baseline and at 15-minute intervals intraoperatively. Pain scores and complications were documented postoperatively. Data were analyzed using SPSS version 25.0. Continuous variables were expressed as mean ± standard deviation and analyzed using one-way ANOVA. Categorical variables were compared using the Chi-square test. A p-value of <0.05 was considered statistically significant.

A total of 90 patients were analyzed, with 30 in each group: Group A (General Anesthesia), Group B (Spinal Anesthesia), and Group C (Combined Spinal-Epidural). Baseline demographic parameters such as age and BMI were comparable among the three groups (p>0.05).

Intraoperative Hemodynamic Stability
Patients in Group A experienced significantly more fluctuations in mean arterial pressure and heart rate compared to Groups B and C. Group C showed the most stable hemodynamics intraoperatively. Hypotensive episodes occurred in 20% of Group A, 13.3% of Group B, and only 6.6% in Group C (Table 1).

Postoperative Pain Scores (VAS)
At 2 hours post-surgery, mean VAS scores were highest in Group A (6.2 ± 1.0), moderate in Group B (4.8 ± 0.9), and lowest in Group C (3.1 ± 0.8). This trend remained consistent at 6 and 24 hours, with statistically significant differences between groups at all time points (p<0.01) (Table 1).

Incidence of Postoperative Nausea and Vomiting (PONV)
PONV was reported in 30% of Group A patients, 10% in Group B, and only 6.6% in Group C. The use of rescue antiemetics was higher in Group A compared to the other groups (p=0.01) (Table 1).

Surgical Duration and Analgesic Requirement
The average duration of surgery did not differ significantly between the three groups (p=0.71). However, the need for rescue analgesia was highest in Group A (73.3%) compared to Group B (46.6%) and Group C (20%).

Table 1: Comparison of Intraoperative and Postoperative Parameters Among Groups

Table 1: Comparison of hemodynamic events, pain scores, and complications across anesthetic techniques.

The present study demonstrates that the choice of anesthetic technique significantly influences intraoperative hemodynamic stability, postoperative pain levels, and the incidence of postoperative nausea and vomiting (PONV) in patients undergoing invasive gynecological surgeries. These findings are consistent with previous research highlighting the importance of individualized anesthetic approaches in optimizing perioperative outcomes (1,2).

General anesthesia (GA), although widely used due to its applicability in a variety of surgical procedures, was associated in this study with greater hemodynamic fluctuations and higher rates of PONV. This aligns with prior literature reporting GA-induced sympathetic stimulation, volatile agent-related vasodilation, and the emetogenic potential of inhalational anesthetics (3,4). In contrast, regional techniques, particularly combined spinal-epidural (CSE) anesthesia, showed better cardiovascular stability. Several studies have indicated that regional blocks attenuate the stress response and reduce perioperative hemodynamic variability (5,6).

Postoperative pain management is a critical determinant of surgical recovery. In our findings, VAS scores were consistently lower in the CSE group at all time intervals, suggesting superior analgesic efficacy. This is corroborated by other clinical trials where CSE has demonstrated enhanced pain control due to the combined effect of rapid-onset spinal anesthesia and prolonged epidural analgesia (7,8). Furthermore, reduced need for rescue analgesics in this group supports its role in improving patient comfort and satisfaction (9).

The incidence of PONV, highest in the GA group, reflects the emetogenic profile of general anesthetics, especially in combination with opioid administration (10). In contrast, spinal and CSE anesthesia are associated with lower systemic opioid requirements, thereby reducing gastrointestinal side effects (11). This was evident in our study where CSE showed the least PONV occurrence, echoing outcomes from previous randomized controlled trials (12).

Although surgical duration did not differ significantly between the groups, the overall perioperative experience—including recovery time and need for analgesia—was notably better in patients receiving regional or CSE techniques. This finding underscores the growing preference for neuraxial techniques in lower abdominal and pelvic surgeries (13).

Our study has a few limitations. The sample size was relatively small, and the procedures were limited to elective surgeries only. Additionally, long-term outcomes such as hospital stay duration and patient-reported recovery measures were not assessed. Despite these constraints, the results contribute meaningfully to the body of evidence supporting the use of CSE in gynecologic procedures.

Future studies should explore multimodal analgesic approaches in conjunction with CSE and assess their effects on enhanced recovery after surgery (ERAS) protocols in gynecology (14,15).

This study concludes that combined spinal-epidural anesthesia offers superior postoperative analgesia, greater hemodynamic stability, and a lower incidence of complications such as PONV compared to general and spinal anesthesia alone in invasive gynecological surgeries. Therefore, CSE should be considered the preferred technique when clinically appropriate to enhance patient outcomes and recovery.

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