Spinal anaesthesia versus general anaesthesia for laparoscopic cholecystectomy: a comparative study

INTRODUCTION

Laparoscopic cholecystectomy is a gold standard surgical treatment of symptomatic cholelithiasis.¹ It may be due to minimally invasive nature of the procedure and associated with less postoperative pain, reduced hospital stay, and earlier return to daily activities.^2,3 When it is performed under general anaesthesia, it may cause postoperative pain and nausea and vomiting. Spinal anaesthesia is a less invasive anaesthetic technique that has lower morbidity and mortality rates, compared with general anesthesia.⁴ Spinal anaesthesia is a less invasive and has lower morbidity and mortality rates as compared to general anaesthesia. Under spinal anaesthesia patient is awake, there is no airway instrumentation, less postoperative pain and absence of nausea and vomiting.⁵ Also the cost effectiveness of spinal anaesthesia makes it an attractive choice. The limiting factor for use of spinal anaesthesia in laparoscopic cholecystectomy was the patient discomfort because of respiratory embarrassment associated with pneumoperitoneum and the shoulder tip pain.⁶

Patients who received spinal anesthesia undergoing laparoscopy interventions are usually awake, felt less pain, and tended to ambulate earlier with no intubation and/or extubation.^7,8 Secondly, the immediate postoperative period is viewed positively by patients due to the absence of general anesthetic side effects (e.g., nausea and vomiting) and less pain experienced due to the effect of persistent neuraxial blockage. Third, patients that have received spinal anesthesia tend to ambulate earlier than patients receiving general anesthesia. Finally, pain related to intubation and/or extubation can be prevented by administering selective spinal anesthesia to patients undergoing laparoscopic interventions. Combining a minimally invasive surgical procedure with a less invasive anesthetic technique appears, theoretically, to further enhance the advantages of LC. Despite the above-mentioned advantages, the use of regional anesthesia for LC has initially remained limited to those patients with pulmonary disease who are at high risk when having general anesthesia.^8,9

Spinal anesthesia (SA) as an alternate to GA was first used by Hamad MA et al for laparoscopic cholecystectomy.¹⁰ Since all laparoscopic procedures are merely a change in access and still require the same anesthesia; hence the difference from conventional surgery is likely to be small. It is therefore expected that SA can be as effective in open cholecystectomy as in laparoscopic approach. In fact, SA with lesser effect on respiratory functions, better post operative pain control, reduced surgical stress response and lower incidence of deep venous thrombosis, can be a better choice than GA.Spinal anaesthesia is more effective than GA in blunting the neuroendocrine stress and adverse responses to surgery.^11,12

METHODS

Study area

The study was conducted in the Department of Anaesthesiology and Critical Care GS Medical College.

Study period

The study was carried out over a period of one year, from January 2021 to December 2022.

Study design

This was a prospective comparative study.

Study population

The study population consisted of patients aged 18–70 years who presented to the Department of Surgery and were scheduled to undergo cholecystectomy during the study period.

Inclusion criteria

Patients were included in the study if they belonged to the American Society of Anesthesiologists (ASA) physical status classification I or II, were aged between 20 and 70 years, and were willing to participate in the study after providing written informed consent.

Exclusion criteria

Patients were excluded from the study if they had a body mass index greater than 35 kg/m², a history of previous open surgery involving the upper abdomen, or the presence of any medical condition that contraindicated elective surgery or spinal anaesthesia.

Sample size

A period-based sampling method was employed, and a total of 100 patients were enrolled in the study.

Group allocation

The participants were divided into two groups based on the type of anaesthesia administered. Group 1 comprised 50 patients who underwent cholecystectomy under spinal anaesthesia, while Group 2 included 50 patients who underwent the procedure under general anaesthesia.

Methodology

After approval from the medical ethical committee and obtaining an informed consent from 100 patients. Taking the patients to the operation theatre, an intravenous line was secured in the right upper limb and infusion of 500 ml of Ringer's Lactate solution started. Blood pressure cuff, ECG electrode and capnography monitor were applied. The initial pulse, blood pressure (BP), respiratory rate, ECG and end tidal CO 2 (EtCO 2) were noted. All the patients were premeditated with Inj. Glycopyrrolate 4 mcg/kg, Inj. Midazolam 0.02 mg/kg and Inj. Ondensetron 0.08 mg/kg intravenously (i.v.).

In Group 1 (spinal anesthesia), the patient was first made to lie in supine position and all the monitors were attached. Oxygen was then administered through ventimask at 3 L/minute. Then the patient was made to lie in left lateral decubitus position. A 25-G Quincke spinal needle was introduced in subarachnoid space at L3-L4 interspace under all aseptic and antiseptic precautions. After confirming free flow of cerebrospinal fluid, 0.3 mg/kg of hyperbaric Bupivacaine 0.5% was injected intrathecally in cephalad direction at a velocity of 0.1 ml/second. Then, after keeping the patient in the 15 o Trendelenberg position for 5 minutes, the patient was again made to lie in a supine position. Approximately 10 minutes after intrathecal injection, the level of analgesia was checked. During this period, 500 ml of 0.9% Ringer's Lactate was infused. A segmental sensory (pin-prick) block, extending between T4 and L5 dermatomes, was obtained without any respiratory distress.

Laparoscopic cholecystectomy was performed using the same techniques in both the groups with standard 4 trocar insertion. After painting and draping, Inj. Bupivacaine plain (0.2%) 20 ml was injected subcostally under diaphragm equally on both sides in both the groups.^9,10 Pneumoperitoneum was established by using the open (Hassen) technique with carbon dioxide at maximum intra-abdominal pressure of 12 mm Hg. Intraoperatively, the patients randomly allocated to general anesthesia group received fentanyl citrate 2 μg/kg i.v. as an adjuvant while those allocated to spinal anesthesia group were given 25 μg i.v. as bolus and when required. All the patients were monitored continuously both for clinical observation and noninvasive hemodynamic monitoring like electrocardiography, pulse, blood pressure, respiratory rate, pulse oxymetry and EtCO 2 which were recorded at 15-minute interval. Operative times as well as any intraoperative events such as shoulder pain, headache, nausea, and discomfort were recorded.

Postoperative pain was assessed at 4, 8, 12 and 24 hours by using the Visual Analogue Scale (VAS) after completion of procedure. Other postoperative events, either related to surgical or especially to anesthetic procedure, such as discomfort, nausea and vomiting, shoulder pain, urinary retention, pruritus, headache and other neurological sequel, were recorded. Operative time in both groups as well as any intraoperative adverse effects like bradycardia, hypotension, nausea, vomiting, headache, and abdominal discomfort were recorded in group 1. Drug consumption and fluid intake were also recorded.

RESULTS

Table 1 shows that in Group 1 among 50 patients, the mean age was found to be 47.32 years and Group B was 46.33 years. Majority of them were females in both the groups. The mean operation time was 37.08 minutes for Group 1 and 42.12 minutes in group 2.

Above Table 2 shows that nausea was seen in both the groups. Dizziness was seen among 09 patients of group 2. Pruritis was see in only 1 patient of Group 1 and urine retention was seen in 2 patients of group 1. Headache was seen in 13 patients of group 1 and 05 patients of group 2.

Table 3 shows that out of 5 the mean VAS was 1.4 at 4 hours, 1.8 at 8 hours and 12 hours and 0.7 at 16 hours in Group 1. In group 2, it was 2.3 at 4 hours and at 16 hours it was 2.7

Patient satisfaction was more in spinal anaesthesia group as compared to general anaesthesia group whereas surgeons satisfaction was more in Group 2.

Mean heart rate was found to be 76.2 and 87.6 in group 1 and 2 respectively at 180 min (Table 4).

Mean systolic BP was found to be 122.5 and 132.4 in group 1 and 2 respectively at 180 min (Table 5).

Mean systolic BP was found to be 83.5 and 87.2 in group 1 and 2 respectively at 180 min (Table 6).

DISCUSSION

In our study, the mean age was found to be 47.32 years in Group 1 and in Group 2 was 46.33 years. Majority of them were females in both the groups. The mean operation time was 37.08 minutes for Group 1 and 42.12 minutes in group 2. the mean VAS was 1.4 at 4 hours, 1.8 at 8 hours and 12 hours and 0.7 at 16 hours in Group 1. In group 2, it was 2.3 at 4 hours and at 16 hours it was 2.7. Patient satisfaction was more in spinal anaesthesia group as compared to general anaesthesia group whereas surgeons satisfaction was more in Group 2.

CONCLUSION

Spinal anaesthesia is associated with less postoperative pain and postoperative nausea and vomiting compared with general anesthesia.Patients receiving spinal anesthesia had shorter discharge time and better satisfaction.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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