Segmental Thoracic Spinal Anesthesia for Laparoscopic Cholecystectomy with the “Hypobaric” Technique: A Case Series

Abstract

Purpose

Several studies have applied lumbar spinal anesthesia (SA) with isobaric/hyperbaric bupivacaine and opioids in elective laparoscopic cholecystectomy (LC), documenting a superiority of the methodic over general anesthesia (GA) in terms of perioperative pain, nausea, and vomiting, though with a notable incidence of intraoperative right shoulder pain, potentially responsible for conversion to GA. This case series presents an opioid-free scheme of segmental thoracic spinal anesthesia (STSA) with hypobaric ropivacaine, reporting its benefits mainly in terms of shoulder pain occurrence.

Patients and Methods

Hypobaric STSA was performed in nine patients undergoing elective LC between May 1 and September 1, 2022. The level of the needle insertion was included between T8 and T9, via a median or a paramedian approach. Midazolam (0.03 mg/kg) and Ketamine (0.3 mg/kg) were used as adjuvants for intrathecal sedation, followed by the administration of hypobaric ropivacaine 0.25% at a dose of 5 mg and then isobaric ropivacaine at a dose of 10 mg. Patients were placed in anti-Trendelenburg position for the entire duration of surgery. LC was conducted through the standard 3 or 4 ports technique with pneumoperitoneum maintained at a pressure of 8–10 mmHg.

Results

Mean patient age was 75.7 (±17.5) years, with a mean ASA score and Charlson comorbidity index (CCI) of 2.7 (±0.7) and 4.9 (±2.7), respectively. STSA was completed without complications in all patients, with no need for conversion to GA. Mean operative time and SA duration were 37.5 (±8.7) and 145.2 (±21.8) min, respectively. Intraoperatively, no shoulder or abdominal pain and nausea were reported, with only four and two patients requiring vasopressor and sedative intravenous drugs, respectively. Postoperatively, overall mean VAS pain score and within the first 12 hafter surgery were 3 (±2) and 4 (±2), respectively. Median length of stay was 2 (range = 1–3) days.

Conclusion

Hypobaric opioid-free STSA appears to be a promising approach for laparoscopic surgeries, with minimal to null occurrence of shoulder pain. Larger prospective studies are required to validate these findings.

Keywords:

• thoracic spinal anesthesia
• laparoscopic cholecystectomy
• hypobaric ropivacaine
• intrathecal midazolam
• intrathecal ketamine

Abbreviations

ASA, American Society of Anesthesiologists; BMI, body mass index; CCI, Charlson comorbidity index; COVID-19, coronavirus disease 2019; GA, general anesthesia; INRCA, Italian National Research Center on Aging; LA, lumbar anesthesia; LC, laparoscopic cholecystectomy; NA, neuraxial anesthesia; NSAIDs, non-steroidal anti-inflammatory drugs; PACU, post-anesthesia care unit; PDPH, post-dural puncture headache; PONV, postoperative nausea and vomiting; RA, regional anesthesia; SA, spinal anesthesia; STSA, segmental thoracic spinal anesthesia; VAS, visual analogue scale.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.

Additional information

Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.