European Journal of Cardiovascular Medicine

General anaesthesia (GA) has been considered gold standard technique for all laproscopic surgeries since long time. But gradually with new safer drugs, alternate techniques are gaining popularity to provide safe anaesthesia with equally good patient satisfaction. In lumbar spinal anaesthesia (SA) the spinal needle and drug is injected at lumbar spaces and since adult spinal cord ends at L ₁ – L ₂ level, it is considered safe in terms of iatrogenic injury to spinal cord and chances of high or total spinal anaesthesia. But in today’s scenario with modern equipments and new researches it is established that thoracic spinal puncture causes no high risk of iatrogenic injury and with availability of new isobaric drugs like levobupivacaine chances of high or total spinal is completely eliminated as the effect is limited to particular chosen and targeted spinal segments and also because the drug spread is limited by natural curvature of vertebral column. It provides better patient satisfaction, post- operative pain management with lower incidence of PONV, and avoids airway manipulation.

Laparoscopic Tubal Ligation is a very common procedure performed on day care basis all over the world. It is commonly performed under Local anaesthesia with sedation or under general anaesthesia. In our tertiary care medical institute GA with face mask ventilation or supraglottic device is routinely used for such procedures. But with gradual expertise in thoracic segmental spinal anaesthesia (TSS) in various other surgical laparoscopic procedures, we conducted 10 cases of laparoscopic tubal ligation under TSS which is discussed below

We conducted 10 cases of thoracic segmental spinal anaesthesia in patients undergoing Laproscopic Tubal Ligation. All female patients belonged to American society of Anaesthesiologist (ASA) physical classes I and II. No patients had allergy to local anaesthetics or any contraindication to spinal anaesthesia. We made sure all patients were able to comprehend VAS pain assessment score. Subarachnoid block was explained to each patient. Written and informed consent was obtained after thorough routine pre-anaesthetic assessment which included investigations like, complete blood count (CBC), Prothrombin time (PT), INR, Serum creatinine (S.Cr.), Serum electrolytes (S.ele), SGPT, blood group (BG), Chest Radiograph (CXR) and baseline Electrocardiogram (ECG). All investigations were within normal limits. Nil per oral status of 8 hours (solids) and 2 hours (clear liquids) was ensured in each patient. Intravenous access was achieved with 20 gauge IV cannula. Inj. Midazolam 1mg, Inj. Glycopyrolate 0.2 mg, Inj. Pantaprazole 40 mg were given as pre-medications 10 minutes before the procedure. Standard ASA monitors (ECG, non-invasive blood pressure [NIBP], pulse oximeter [SpO₂] and capnometry [EtCO₂] were attached and baseline parameters were noted in each patient. Inj. Ringer lactate 10ml/kg was pre-loaded over 20 minutes before performing subarachnoid block. For spinal anaesthesia, patients were positioned in sitting position on the operating table. After painting and draping, lower angle of scapula was palpated to identify T₇-T₈ intervertebral space in the midline. The overlying skin and subcutaneous tissue was infiltrated with Lignocaine 1% 2-3 ml after which 25 Gauge Quincke’s spinal needle was inserted in midline interverbral space and after ensuring free CSF flow, isobaric Levobupivacaine 0.5 % 1.5-2 ml (according to patient’s height) was slowly injected at the rate of 0.2 ml/second. Patients were then placed in supine position and the level of sensory block assessed with pinprick sensation. Sensory block of T₄-L-₁ was considered adequate and the surgeon as then asked to proceed for surgery. Inj. Fentanyl 1.5 μgm/kg was given in all patients before pneumoperitoneum. Patients were kept in horizontal position before trocar insertion, and after pneumoperitoneum patients were immediately placed in steep Trendelenburg position to minimize shoulder tip pain by CO₂ insufflation. Bradycardia and hypotension at any time were defined as >=20% reduction in NIBP/heart rate. Hypotension was treated with IV Ringer lactate bolus/ Mephentermine 6 mg boluses and bradycardia was treated with IV atropine 0.6 mg. Intra-abdominal pressure ranged from 10-12 mmHg in all patients. After the procedure and after CO₂ desufflation patients were placed in horizontal position and transferred to PACU where they were monitored till discharged. The overall pain experienced during the procedure was measured as VAS score immediately at the end of the surgery. In PACU, VAS score, Heart rate, NIBP, SpO₂ were assessed every half hourly till discharge. Other parameters noted were duration of sensory block, time to first oral intake, time to first void urine and time to ambulate. Table 1 and Table 2 show demographic characteristics, pre-operative investigations, intra-operative variables, and post-operative VAS scores of all patients.

Table 1: Demographics, surgical characteristics and clinical results of patients.

[*CBC- Complete blood count as Hb in gm%/ Total WBC per cumm/Total platelets per cumm

**S.electrolytes mentioned as Na/K

NS- not significant]

Table 2: Post-operative characteristics of patients.

Laproscopic surgeries require correct positioning, decompression of the gastrointestinal tract (GI tract), adequate pneumoperitoneum and good muscle relaxation. Therefore GA has been traditionally used for all laparoscopic surgeries with the apprehension that adequate relaxation may not be possible in spinal anaesthesia for laparoscopy. Another cause of concern is shoulder tip pain due to diaphragmatic irritation with pneumoperitoneum which is abolished with GA. But as the number of cases of laparoscopy have increased over the years, regional anaesthesia has gained popularity with the introduction of newer safer drugs and techniques.

There are various studies where lumbar SA has been successfully and safely used for laparoscopic surgeries of Gall Bladder and Appendix.^[1,2] There are also studies which have stated that use of epidural or spinal anaesthesia is quite safe for laparoscopy in ASA grade I patients.^[3]

GA warrants an extra time for induction. Pulmonary function takes 24 hours to return to normal after laparoscopic surgery performed under GA.^[4] Increased PaCO2 concentrations after CO2 pneumoperitoneum has been observed in patients under GA as compared to when the patients are breathing spontaneously under regional anaesthesia.^[5] Patients with GA have an additional problem of stomach inflation during mask ventilation, which needs to be deflated with Ryle’s tube.

Post laparoscopic shoulder pain is seen when the intra-abdominal pressure is kept high. Also, the complications following endotracheal intubation like sore throat, laryngeal oedema, hoarseness, and tracheal injuries are avoided when SA is used. Requirement of analgesia is immediate after GA, while in SA it is generally 2-3 hours after surgery.

While SA provides excellent muscle relaxation, decreased surgical bed oozing, and a rapid return of gut function, good post-operative analgesia, decreased incidence of PONV (post-operative nausea and vomiting), it has also proved to be cost-effective and time-saving. There are also studies which show efficacy of SA for short duration gynaecologic laparoscopy which includes laproscopic tubal ligation.^[6,7,12] Laproscopic tubal ligation is a short duration surgery (10-20 minutes) when done uneventfully and with expert hands. SA is such surgeries can prove to be a safe and time-saving alternative. But one issue of concern with SA is hypotension which can be aggravated with increased intra-abdominal pressure due to pneumoperitoneum. This can be avoided by using the technique of Thoracic segmental spinal anaesthesia (TSS).

Anaesthesiologists are hesitant to perform SA above the termination of the conus medullaris due to fear of injuring the spinal cord. However, TSS has been demonstrated as a safe and effective method for various surgeries, including laparoscopic cholecystectomies, breast cancer lumpectomies, and abdominal cancer surgery.^[8,9,10] MRI images have shown that the mid to lower thoracic segment of the spinal cord lies anteriorly, where there is a CSF-filled space between the dura and the cord.^[11] In contrast, the spinal cord and the cauda equina are touching the dura mater posteriorly in the lumbar region. This has demonstrated there is a greater depth of the posterior subarachnoid space in the thoracic spinal cord and hence higher safety margin.  In one MRI imaging study with 50 patients, the space between the dura mater and spinal cord in the thoracic spine measured at 7.75 mm at T5 and 5.88 mm at T10.^[11] Thus, intrathecal injections at mid-thoracic levels may have a minimum safe distance before the spinal needle contacts the spinal cord tissue. Apart from this low volume of local anaesthetic agent reduces the incidence of hypotension/bradycardia. In our cases we used 1.5-2 ml of isobaric Levobupivacaine 0.5% at the T₇-T₈ segmental level. Isobaric drug helps in providing selective spinal anaesthesia to desired levels, in our cases between T₄ and L₁. The incidences of bradycardia were noted in 3 cases which was quickly reverted with atropine 0.6 mg. In none of the cases HR reduced below 50 bpm. Similarly hypotension occurred in 2 cases where single dose of 6 mg mephentermine sufficed. We gave IV fentanyl to all patients in the maximum dose of 1.5 μgm/kg which covered any residual pain from diaphragmatic irritation and pain from cervical manipulation. The intraoperative VAS pain score ranged from 1-3 in all cases which was satisfactory. The duration of surgery ranged from 10-25 minutes. All patients were able to void urine spontaneously within 2-3 hours. The time to first analgesic was 3-4 hours post-operatively. All patients were able to discharge from PACU within 3-4 hours and were able to ambulate within 6 hours.

Thoracic segmental spinal anaesthesia (TSS) offers many benefits not available with general anaesthesia or with lumbar spinal anaesthesia. The anaesthetic dose is lower, which causes minimal hemodynamic instability intra-operatively.

In Pneumoperitoneum under TSS, spontaneous breathing results in an increase in minute ventilation with unchanged ETCO2. There is an earlier recovery of bowel/ bladder function, reduced incidence of PONV, excellent post-operative analgesia, earlier ambulation, all of which results in a shorter length of in-hospital stay and patient satisfaction.

Acknowledgements

The cases were conducted with clinical support from post graduate resident students and technical support by nursing staff and operation theatre staff of Gynaecology operation theatre, GMERS Medical College and civil hospital, Gandhinagar.

Conflict Of Interest

The authors declare no conflicts of interest.

FUNDING

No financial support was needed at any point of study

1. Sinha R, Gurwara AK, Gupta SC. Laparoscopic surgery using spinal anaesthesia. J Soc Laparoendosc Surg 2008;12(2):133-8.
2. Singh RK, Saini AM, Goel N, et al. Major laparoscopic surgery under regional anaesthesia: a prospective feasibility study. Med J Armed Forces India 2015;71(2):126-31
3. Erdem VM, Donmez T, Uzman S, et al. Spinal/epidural block as an alternative to general anaesthesia for laparoscopic appendectomy: a prospective randomized clinical study. Wideochirurgia I Inne Tech Maloinwazyjne 2018;13(2):148-56.
4. Palachewa K, Chau-In W, Naewthong P, et al. Complications of spinal anaesthesia at Stinagarind hospital. Thai J Anesth 2001;27:7-12.
5. Throngnumchai R, Sanghirun D, Traluzxamee K, et al. Complication of spinal anaesthesia at Lerdsin hospital. Thai J Anesth 1999;25:24-7.
6. Stewart AVG, Vaghadi H, Collins L, et al. Small-dose selective spinal anaesthesia for short-duration outpatient gynaecological laparoscopy: Recovery characteristics compared with propofol anaesthesia. Br J Anaesth 2001;86(4):570-2.
7. Sarkar P, Singh Y, Patel N, Kumar S, Khanna P, Kashyap L, et al. Safety and efficacy of low‑dose selective spinal anesthesia with bupivacaine and fentanyl as compared to intravenous sedation and port‑site infiltration for outpatient laparoscopic tubal ligation: A randomized controlled trial. Anesth Essays Res 2021;15:290-5.
8. Hamad MA, El-Khattary OA. Laparoscopic cholecystectomy under spinal anesthesia with nitrous oxide pneumoperitoneum: a feasibility study. Surg Endosc. 2003 Sep;17(9):1426-8. [PubMed: 12802665]
9. Elakany MH, Abdelhamid SA. Segmental thoracic spinal has advantages over general anesthesia for breast cancer surgery. Anesth Essays Res. 2013 Sep-Dec;7(3):390-5. [PMC free article: PMC4173558] [PubMed: 25885990]
10. Ellakany MH. Thoracic spinal anesthesia is safe for patients undergoing abdominal cancer surgery. Anesth Essays Res. 2014 May-Aug;8(2):223-8. [PMC free article: PMC4173607] [PubMed: 25886230]
11. Imbelloni LE, Quirici MB, Ferraz Filho JR, Cordeiro JA, Ganem EM. The anatomy of the thoracic spinal canal investigated with magnetic resonance imaging. Anesth Analg. 2010 May 01;110(5):1494-5. [PubMed: 20304985]
12. Chilkund JN, Gadgil JJ. Gynaecologic laparoscopic surgery using spinal anaesthesia- a retrospective observational study. J. Evolution Med. Dent. Sci. 2020;9(12):924-927, DOI: 10.14260/jemds/2020/199.