regional anesthesia for laparoscopy

ANESTHESIA FOR MINIMALLY INVASIVE SURGERY LAPAROSCOPY, THORACOSCOPY, HYSTEROSCOPY 0889-8537/01 $15.00 + .OO

REGIONAL ANESTHESIA FOR LAPAROSCOPY

Linda M. Collins, MB, BCh, BAO, FFARCSI and Himat Vaghadia, MD, MB, BS, FRCPC

Laparoscopy is becoming one of the most common surgical procedures performed on an outpatient basis. Technical advances in the field of endoscopic surgery, such as the miniaturization of instruments, the use of "gasless" endoscopy, and the use of more efficient lighting techniques, will help to reduce surgical trauma and discomfort and thereby widen the scope of laparoscopy. The driving forces behind such techniques are that anesthetic requirements will be reduced and result in an abbreviated hospital stay.

Socioeconomic pressures from limited healthcare resources and the constant strife for optimizing patient care lead researchers to seek anesthetic techniques with minimal morbidity for such procedures. General anesthesia as the only suitable technique for laparoscopic procedures is a concept of the past. A problem with modern general anesthetics is that even though patients can be awake and oriented shortly after cessation of the anesthetic, these agents do not facilitate postoperative analgesia or an emesis-free recovery, two important problems associated with laparoscopy. There is a growing body of evidence suggesting that regional anesthesia has an important role to play in the care of patients undergoing laparoscopy. The scope of regional anesthesia depends on the creativeness of surgeons and anesthesiologists, and patient acceptance. This article proposes to outline various ways of using regional anesthesia for patients undergoing laparoscopic abdominal surgery.

From the Department of Anaesthesia, Vancouver Hospital and Health Science Center, Vancouver, British Columbia, Canada

ANESTHESIOLOGY CLINICS OF NORTH AMERICA

VOLUME 19 NUMBER 1 MARCH 2001 43

44 COLLINS & VAGHADIA

ADVANTAGES AND DISADVANTAGES OF REGIONAL/ LOCAL ANESTHESIA

No single anesthetic technique or agent has been demonstrated to be ideal for laparoscopy. The choice of agent and technique must be determined after consideration of patient factors, surgical needs, and the anesthesiologist’s capabilities. Advantages of regional anesthesia are multiple. Patients have less emesis4, 35 than after general anesthesia and experience less postoperative pain.l4, 32, 33 The ability to be awake during surgery and be able to communicate with the surgeon can be perceived as an advantage by many patients and is a requirement for pain mapping in patients with nonspecific pain syndromes. Regional anesthesia is also cost effective and conducive to accelerating the discharge process in selected cases.

Patients who are unsuitable for regional anesthesia include those unwilling to cooperate, who have difficulty in coping with the surgical suite environment, who have a language barrier, or who are very anx- ious. Surgical needs vary according to the planned procedure. A short laparoscopy for tuba1 sterilization could require minimal relaxation of the abdominal wall and minimal Trendelenburg tilt. Extensive procedures requiring considerable manipulation of viscera could require good relaxation and steep Trendelenburg tilt. Regional anesthesia as a sole technique might not be suitable for the latter type of procedure.

Disadvantages of regional anesthesia include the need for a coopera- tive patient and the problem of shoulder and upper chest discomfort as a result of diaphragmatic irritation from insufflated g a s e ~ . ~ , ~ ~ Insufflating pressures sometimes have to be kept low (<15 mm Hg) and the degree of Trendelenburg positioning minimized to reduce patient discomfort and increase acceptance. Regional anesthesia also can be limited in its scope to procedures of well-defined duration and extent of surgical intervention. Obese patients or those who have had previous abdominal surgery (with a risk of pelvic adhesions) might not be amenable to regional anesthesia techniques. Patients also must be alert enough to be able to protect their airway owing to the risk of gastroesophageal reflux from increased intra-abdominal pressures. Perceptions of reduced time efficiency with regional anesthesia continue to be important obstacles to the implementation of regional anesthesia. Recent studies do confirm that the extra time spent inducing regional anesthesia is more than made up in a faster exit time from the surgical suite and a shorter postoperative stay, however.@

PHYSIOLOGIC CONSIDERATIONS FOR LAPAROSCOPY IN AN AWAKE PATIENT

The creation of a pneumoperitoneum gives rise to several considerations unique to laparoscopic surgery. The abdominal cavity is insufflated

REGIONAL ANESTHESIA FOR LAPAROSCOPY 45

with carbon dioxide (CO,), and the patient is placed in a Trendelenburg position (for gynecologic procedures), both of which create respiratory and hemodynamic changes.

To achieve a pneumoperitoneum, CO, is insufflated at abdominal pressures of 10 mm Hg to 15 mm Hg. The increased intra-abdominal pressure leads to a decrease in total lung compliance and functional residual capacity (FRC), resulting in basal atelectasis and increased airway pressures. The result is impairment in ventilation/perfusion (V/Q) in many lung units. In addition, insufflation of CO, also increases CO, ab~orption.~ The ventilatory effects of laparoscopy on patients under general anesthesia have been studied by Puri et a1,2* who found that there was an increase in CO, elimination after insufflation that continued until 10 minutes postdeflation of the abdomen. There was a correspond- ing rise in arterial CO, (Paco,) concentrations. The Pace, declined in the recovery period, which was consistent with a decrease in CO, production and an increase in the ability of a spontaneously breathing patient to eliminate CO,. A mean difference between arterial and end-tidal CO, (ETco,) tension of 0.44 kPa has been reported with general and epidural anesthesia .3

These respiratory changes are less evident when laparoscopy is performed with the patient under regional anesthesia. An increase in CO, concentrations was not observed during laparoscopy in patients breathing spontaneously during epidural ane~thesia.~ The creation of the pneumoperitoneum resulted in an increase in minute ventilation with an unchanged ETco,? In contrast to general anesthesia, the Trendelenburg position during epidural anesthesia did not lead to significant changes in ventilatory parameters. Despite the increase in respiratory work and V/Q mismatch, alveolar ventilation was not compromised, because the increase in minute ventilation reduced the respiratory effects of laparoscopy. Under epidural anesthesia, the respiratory control mechanism remains intact, allowing the patients to adjust their minute ventilation. Multiple studies have confirmed that arterial blood gases during laparoscopy under regional anesthesia are maintained within normal limits."

Hemodynamic changes during laparoscopy have been studied mainly after induction of general anesthesia and following CO, insuffla- ti011.l~ Most studies have reported an increase in systemic vascular resistance and mean arterial pressure, and a decrease in cardiac index, with minimal changes in heart rate. No change in mean arterial pressure or heart rate during Trendelenburg positioning or insufflation is found in patients undergoing epidural ane~thesia.~ With hyperbaric spinal anesthesia, there is a tendency for the level of block to migrate in the cephalad direction during the Trendelenburg position, thus increasing the magnitude of sympathectomy and predisposing to the development of hypotension and brady~ardia.4~ Conversely, low-dose hypobaric solutions do not migrate cephalad in the Trendelenburg position, and the risk of hypotension is reduced.


LOCAL ANESTHESIA TECHNIQUES

Various regional blocks, including rectus sheath block, inguinal block, spinal anesthesia, and epidural anesthesia have been described for laparoscopy as either the principal method of anesthesia or an adjunct to general anesthesia.

Rectus Sheath Block

The rectus sheath block, with successful blockade of the relevant intercostal nerves within the rectus sheath, provides anesthesia of the anterior abdominal wall. This block is induced by two injections, one on each side of the abdomen. A 22-gauge short bevel needle is inserted at a point 3 cm to 5 cm above the level of the umbilicus at the lateral border of the rectus abdominis. The anterior rectus sheath is identified by moving the needle from side to side while advancing the needle until it is felt to scratch the sheath. The needle is advanced until the resistance of the posterior layer of the rectus sheath is felt. Bupivacaine 0.25%, 0.25 mL/kg, is then injected after a negative aspiration 33 When administered in conjunction with general anesthesia, rectus sheath block resulted in improved postoperative analgesia (decreased pain scores and reduced consumption of analgesics) and facilitated discharge. Of note, this block does interfere with the patient’s ability to perform a sustained head lift.

Inguinal Block

Innervation of the inguinal region is from the iliohypogastric and ilioinguinal nerves, which have their origins from the first and second lumbar nerves. These nerves, along with the 12th thoracic nerve, course anteriorly and pass near the anterior superior iliac spine. The 12th thoracic and the iliohypogastric nerves lie between the internal and external oblique muscles. The ilioinguinal nerve lies between the transversus abdominis muscle and the internal oblique muscle initially, and then penetrates the internal oblique muscle some distance medial to the anterior superior spine. All the nerves continue anterior medially and become superficial as they terminate in the skin and muscles of the inguinal region. The inguinal block is performed with the patient lying supine. An 8-cm 22-gauge needle is inserted cephalolaterally approxi- mately 3 cm medial and inferior to the anterior superior iliac spine to contact the inner surface of the ileum. Ten milliliters of local anesthetic solution is injected as the needle is slowly withdrawn through the layers of the abdominal wall. The needle is then inserted at a steeper angle to ensure penetration of all three abdominal muscle layers, and the injection is repeated. From the initial insertion site, a subcutaneous field block is made towards the umbilicus and from umbilicus to pubis. Ilioinguinal/

REGIONAL ANESTHESIA FOR LAFAROSCOPY 47

iliohypogastric blocks are useful adjuncts to general anesthesia for laparoscopic hernia repair. Tobias et a P evaluated the efficacy of caudal epidural block versus local infiltration combined with ilioinguinal/iliohypogastric block for analgesia after inguinal herniorrhaphy with laparoscopic inspection of the peritoneum. They found that caudal epidural block with 1.2 mL/kg of 0.25% bupivacaine resulted in lower postoperative scores and earlier discharge home, as compared with ilioinguinal/ iliohypogastric block.4O

Spinal Anesthesia

Spinal anesthesia is the simplest and most reliable of the regional anesthesia techniques and should be ideal for many outpatient procedures, including laparoscopy? The rapid onset of anesthesia helps to address concerns of time efficiency with regional techniques. The important issues with spinal anesthesia are patients’ attitudes, risk of postdural puncture headache (PDPH), backache, and transient radicular irritation syndrome (TRI). Patients seem to be mostly amenable to spinal anesthesia, their main fears being needle pain, backache, seeing and hearing things in the surgical suite paralysis, and the possibility of a failed spinal block. Patient education is therefore important in improving compliance with this technique. The risk of PDPH has been reduced to fewer than 2% with the advent of small-gauge (25-G-27-G) noncutting (or pencil-point) spinal needles. Back pain does not seem to be associated with needle size or type. TRI is characterized by mild to severe radiating pain in the lower extremities, lower back and buttocks, or both. The pain usually starts within 24 hours after spinal anesthesia, lasts for less than 2 days, and is amenable to oral analgesics. The precise incidence of TRI varies with the local anesthetic used, the institution, and the criteria used for diagnosis. The importance of meticulous technique, rapid injection, barbotage, and the need to use the lowest possible dose/concentra- tion have been empha~ized.~, 34, 43, 44, 46 Plain 1% lidocaine, plain 0.5% bupivacaine, and 1.5% mepivacaine are reported to be acceptable for spinal anesthesia.

Spinal anesthesia as the primary technique for laparoscopy offers many benefits over general anesthesia; however, conventional dose hyperbaric spinal anesthesia might not be ideal for laparoscopy. The Tren- delenburg position predisposes to cephalad spread of the spinal block, a greater sympathetic block, and hyp~tens ion .~~ Administration of reduced doses of the local anesthetics minimizes side effects such as hypotension, bladder distension, and prolonged sensory and motor block traditionally associated with conventional doses. Vaghadia et a143 evaluated the effects of small-dose hypobaric lidocaine (25 mg) in combination with fentanyl (25 Fg) for spinal anesthesia, compared with a conventional dose of hyperbaric 5% lidocaine (75 mg) in patients undergoing short-duration outpatient laparoscopy.’ The patients were seated upright, and spinal anesthesia was performed at the L2-L3 or L3-L4 interspace with a


27-gauge Quincke needle. Surgery commenced once the sensory level of anesthesia reached T6. They found that, in the low-dose group, no hypotension occurred, and motor and sensory recovery were significantly faster compared with that in the patients receiving the conventional dose of local anesthetics. On follow-up study, the level of patient satisfaction with the effectiveness of this type of anesthesia was over %YO, with 90% of patients requesting spinal anesthesia for laparoscopy in the future.

The optimal dose of fentanyl for use with low-dose hypobaric lidocaine-fentanyl spinal anesthesia was found to be 25 pg7 Substitution of fentanyl with sufentanil (10 pg) facilitates reduction of the lidocaine dose from 25 mg to 10 mg without compromising surgical conditions.& The use of 1% lidocaine (10 mg) mixed with sufentanil (10 pg) resulted in selective spinal anesthesia (SSA), with preservation of spinal dorsal column and motor function and a faster sensory (pin-prick) recovery, such that patients were virtually able to fulfill "walk-out" criteria at the end of a laparoscopic procedure lasting for 20 to 30 minutes.% Compari- son of the SSA technique with propofol general anesthesia for mainte- nance showed that all patients with SSA were "fast-track eligible" imme- diately at the end of surgery on reaching the postanesthesia care unit (PACU), unlike those who received propof01.~~ Other surgical procedures, such as laparoscopic inguinal hernia repair with extraperitoneal gas insufflation, have also been accomplished safely and comfortably with spinal ane~thesia.~~ With the advent of gasless laparoscopy and microlaparoscopy, the role of spinal anesthesia probably will increase in the future."

Epidural Anesthesia

An important advantage of epidural anesthesia remains the ability to prolong anesthesia in the event of surgical delays. Lumbar epidural block is a satisfactory anesthetic technique for laparoscopic tuba1 sterilization. Oxygenation during the period of pneumoperitoneum is ade- quate, and the technique resulted in a shortened recovery period and fewer postoperative complications. In addition, surgeon, anesthesiologist, and patient acceptance were e~cellent.~ A variety of procedures have been performed successfully with the patient under epidural anesthesia, including laparoscopic cholecystectomy and laparoscopic ligation of spermatic varices, laparoscopy for in-vitro fertilization, and gynecologic procedures, such as oophorectomy, myomectomy, and hysterectomy8, 12,42

Combined Spinal-Epidural Anesthesia (CSEA)

One disadvantage of epidural anesthesia is the relatively slow onset of anesthesia. Recently, there has been increasing interest in combining spinal and epidural anesthesia (CSEA).*O Potential advantages of CSEA include rapid onset of anesthesia and the ability to administer minimally effective doses of intrathecal agents initially with a resultant decrease in


recovery time. The technique involves location of the epidural space with an epidural needle followed by insertion of a spinal needle through the epidural needle. After intrathecal administration of the spinal anesthetic, the spinal needle is withdrawn and an epidural catheter is placed in the epidural space in the usual manner.

Caudal Epidural Block

Caudal epidural blocks are an effective modality for providing postoperative analgesia after laparoscopic hernia surgery in children. Children receiving caudal anesthesia have lower pain scores and do not require supplemental analgesia in the postoperative period.4I

SURGICAL PROCEDURES PERFORMED UNDER REGIONAL ANESTHESIA

Diagnostic Laparoscopy

Diagnostic laparoscopy is commonly used for the investigation of abdominal and pelvic pathology. Although most laparoscopies are performed under general anesthesia, minilaparoscopy can be performed with the patient under local anesthesia, which can assist in the evaluation of patients with acute abdominal pain. Increasing numbers of these procedures are being carried out in physicians’ offices and freestanding obstetrics and gynecology practices without access to anesthetic service. Almeida et aP assessed the safety of diagnostic and surgical microlaparoscopy performed in the office setting in patients presenting with chronic pelvic pain. All patients tolerated diagnostic and surgical procedures (e.g., fulguration of endometriotic lesions, lysis of adhesions, pain mapping, and uterosacral nerve ablation), and no complications were reported. In a similar setting, Childers et a16 evaluated patients with intraperitoneal carcinomatosis undergoing diagnostic laparoscopy and biopsy under local anesthesia. This procedure safely allowed histologic analysis of disease in a simple, effective, and economical way without the patient’s needing to undergo major surgical procedures.

The use of laparoscopy with local anesthesia has been reported for the diagnosis of suspected appendicitis and been found beneficial in avoiding unnecessary laparotomy in over 70% of the cases.18 In trauma patients, laparoscopy with local anesthesia was found to be useful in improving the management of stab wounds and blunt injuries, and in selected patients, in conjunction with diagnostic peritoneal lavage, allowing further diagnosis and potentially the treatment of injuries without laparot~my.~~ Laparoscopy with local anesthesia has also been used successfully for the diagnosis of acalculous cholecystitis in critically ill patients; the management of as~ities,’~ the detection of disseminated disease in patients with intra-abdominal malignancy so that unnecessary


laparotomy can be avoided: the diagnosis of general surgical problems and vague symptoms,l3 and staging purposes in 0ncology.4~ Zupi et a150 performed minilaparoscopies with the patient under local anesthesia and sedation in patients undergoing investigation for infertility.

Pain Mapping

Endometriosis, a common cause of chronic pelvic pain, traditionally is diagnosed by examination with the patient under general anesthesia. As patient cooperation is helpful in the diagnosis and assessment of painful endometriotic lesions, pain mapping is ideal under local/regional anesthesia. Pain mapping with the patient under local anesthesia and sedation is an accurate method of disease assessment. The progress of medical treatment can also be assessed at regular intervals.1° Surgical intervention (e.g., diagnostic superior hypogastric plexus block) can be performed after initial pain mapping, and, depending on the degree of improvement, patients can be selected for presacral neurectomy.18

Gamete Transfer

Infertility treatment was revolutionized in the late 1970s with the introduction of in vitro fertilization (IVF) and embyro transfer (ET). Initially these techniques were reserved for women with tuba1 obstruc- tion, but the list of treatable disorders now includes male infertility, endometriosis, sperm antibodies, and unexplained female infertility. The initial two-stage technique has expanded to a one-stage gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT). Initially, IVF and ET were performed using the laparoscopic approach with the patient under general anesthesia; however, with the advent of the vagi- nal ultrasound probe, transvaginal oocyte retrieval has become an outpatient procedure that can be performed with local anesthesia and minimal intravenous sedation. The cost benefit of using local anesthesia is an important consideration in a procedure that sometimes must be repeated multiple times (in view of its low birthrate success of 10%-20%).30 Lewin et all9 compared laparoscopic follicular aspiration under general anesthesia to ultrasound-guided follicular aspiration with local anesthesia and found similar oocyte recovery rates (82.5% versus 75%) and similar fertilization rates (61.9% versus 62.5%) in both groups.

Laparoscopic ZIFT procedure also can be performed with the patient under local anesthesia, augmented with intravenous analgesia. Sigrufi- cant discomfort can be minimized by transferring zygotes to one tube only.48 Milki et alZ1 assessed the level of satisfaction in patients undergoing transvaginal ultrasound-guided egg retrieval followed by GIFT under local anesthesia and sedation in a clinic procedure room. The conditions were well accepted by the patients, 98% of them classifying their comfort as acceptable to very good. Pregnancy and delivery rates were


also acceptable (43% and 38%, respectively). Silva et aP1 investigated the feasibility of performing GIFT under spinal anesthesia. Satisfactory anesthesia was obtained in 96% of cases. All patients were discharged home on the day of surgery, no complications were noted until 7 days later, and the pregnancy rate was 43%.

Laparoscopic Tuba1 Ligation

Many different techniques are described for the anesthetic management of laparoscopic tubal ligation. In a randomized study, Peterson et aP6 compared laparoscopic sterilization performed with the patient under either general or local anesthesia. Because of technical difficulties related to obesity, 7.6% of patients in the local anesthetic group required general anesthesia. Hemodynamic stability was greater in the local anesthetic group. Satisfaction was equal among patients in each group (80%).

Hatasaka et all6 compared costs, operating and recovery times, safety, and patient acceptance between minimally invasive laparoscopic tubal ligation with patients under local anesthesia, and conventional laparoscopic tubal ligation with patients under general anesthesia. He reported decreased surgery and recovery times and cost in the minimally invasive group under local anesthesia. No complications were reported with either surgical method. The application of 4% lidocaine to the fallopian tubes at the time of tubal fulguration has been shown to reduce patient discomfort significantly when this procedure is performed with patients under local anesthe~ia .~~

Local anesthesia also has an important role in reducing morbidity in patients under general anesthesia. Haldane et all4 found that a pouch- of-Douglas block was an effective method of postoperative pain relief in patients undergoing laparoscopic sterilization. The preoperative administration of ketoprofen, 100 mg, and perioperative mesosalpinx infiltration with 5 mL bupivacaine 0.5% resulted in shorter times to discharge, a decrease in peripheral analgesic requirements, and a lower incidence of postoperative nausea and vomiting.45 The combination of rectus sheath and mesosalpinx block as an adjunct to general anesthesia provides an effective method of postoperative relief, leading to earlier discharge from the hospital compared with rectus sheath block 33

The pharmacokinetics and pharmacodynamics of lidocaine and bupivacaine were investigated by Spielman et aP6 when used for laparoscopic sterilization under local anesthesia. Either 240 mg of lidocaine or 100 mg of bupivacaine were sprayed onto the fallopian tubes. Venous blood samples were assayed, and the peak concentrations of each agent were well below the convulsive level. These findings justify the use of larger volumes of these local anesthetics when increased postoperative pain is anticipated.


RECOVERY AND DISCHARGE AFTER REGIONAL ANESTHESIA

Patients recovering from regional anesthesia must meet the same discharge criteria as those patients receiving general anesthesia. Surgical facilities vary by the extent to which they use objective and subjective criteria for discharge. Consistent criteria must address the following issues: (1) stable vital signs, (2) resolution of motor and sensory block after neuraxial block, (3) orientation to time, place, and person, (4) pain adequately controlled on oral analgesics, (5) control of nausea and vomiting, (6) absence of bleeding, and (7) ability to ambulate. In many centers, voiding is not considered a prerequisite for discharge after spinal anesthesia. Patients receiving spinal anesthesia should also be warned about the symptoms of postdural puncture headache and transient radicular irritation. Patients who have received a regional block for postoperative analgesia should be given written instructions reminding them that they might not have protective sensation in the affected dermatomes until the block wears off. When large volumes of local anesthetic have been administered for local anesthesia, the patient should be observed long enough to ensure that central toxicity from systemic absorption does not occur.

SAFETY AND PATIENT SATISFACTION

In a study of 1200 laparoscopic sterilizations on patients under local anesthesia, Penfield et alE reported no complications. In 8509 laparoscopic sterilizations on patients under local anesthesia, Pattinson et alZ3 reported major complications (anaphylactic shock after local anesthetic injection) in 1 patient and a technical failure rate of 1.15%. Poin- dexter et a127 reported on 3000 outpatient laparoscopic sterilizations under local anesthesia and found no major complications, a technical failure rate of 0.149'0, and hospital costs that were reduced by 68% to 85%. There are numerous other reports that demonstrate that regional anesthesia is a safe method for many laparoscopic procedures and is well accepted by patient^.^, 7, s, 12, 26, 31* 34, 37, 39, 4~~ With the increasing emphasis on office-based laparoscopic sterilization using local anesthesia with sedation, Miller et a12* retrospectively studied the safety of performing this procedure in that environment and proposed that there was no evidence of increased risk of life-threatening complications.

SUMMARY

A variety of laparoscopic procedures can be performed on patients under regional anesthesia. Diagnostic laparoscopy in elective and emer- gency patients, pain mapping, laparoscopy for infertility, and tuba1 sterilization are some examples. The key benefits of regional anesthesia in-


clude less emesis, less postoperative pain, shorter postoperative stay, improved patient satisfaction, and overall safety. Regional techniques, such as rectus sheath blocks, inguinal blocks, and caudal blocks, are useful adjuncts to general anesthesia and facilitate postoperative analgesia. Other techniques, such as spinal and epidural anesthesia, and combination of the two, are suitable as a sole anesthetic technique for laparoscopy. The physiologic changes during laparoscopy in the awake patient appear to be tolerated well under regional anesthesia. It is reasonable to assume that with advances in instrumentation and surgical techniques, the role of laparoscopy will increase in the future. The benefits conferred by regional anesthesia make it an attractive option to general anesthesia for many patients and procedures. Successful implementation of regional anesthesia is an important determinant of how anesthesiologists, surgeons, and surgical facilities cope with new challenges. In the future, it could be possible to provide "walk-in/walk-out" regional anesthesia with a real possibility of fast tracking patients through the recovery process after ambulatory surgery.44 For maximal patient safety, however, facilities offering regional anesthesia must have appropriately trained anesthesia personnel and the equipment necessary for monitoring and providing full resuscitation in the event of complications or a need to convert to general anesthesia.

References

1. Almeida J, Sleeman D, Sosa JL, et al. Acalculous cholecystitis: The use of diagnostic laparoscopy. J Laparoendosc Surg 5227, 1995

2. Almeida OD Jr, Val-Gallas JM: Office microlaparoscopy under local anesthesia in the diagnosis and treatment of chronic pelvic pain. J Am Assoc Gynecol Laparosc 5:407, 1998

3. Brampton WJ, Watson RJ: Arterial to end-tidal carbon dioxide tension difference during laparoscopy: Magnitude and effect of anaesthetic technique. Anaesthesia 45:210, 1990

4. Bridenbaugh LD, Soderstrom RM: Lumbar epidural block anesthesia for outpaient laparoscopy. J Reprod Med 23:85, 1979

5. Brown DR, Fishbume JI, Robertson VO, et al: Ventilatory and blood gas changes during laparoscopy with local anesthesia. Am J Obstet Gynecol 124741, 1976

6. Childers JM, Hatch KD, Surwit E A Office laparoscopy and biopsy for evaluation of patients with intraperitoneal carcinomatosis using a new optical catheter. Gynecol 011~0147337,1992

7. Chilvers CR, Vaghadia H, Mitchell GW, et a1 Small-dose hypobaric lidocaine-fentanyl spinal anesthesia for short duration outpatient laparoscopy, 11. Optimal fentanyl dose. Anesth Analg W65, 1997

8. Chiu AW, Huang WJ, Chen KK, et al: Laparoscopic ligation of bilateral spermatic varices under epidural anesthesia. Urol Int 5780, 1996

9. Ciofolo MJ, Clergue F, Seebacher J: Ventilatory effects of laparoscopy under epidural anesthesia. Anesth Analg 70:357, 1990

10. Demco LA: Patient-assisted laparoscopy in the diagnosis and management of endometriosis. J Am Assoc Gynecol Laparosc 4:S8, August 1996

11. Diamant M, Benumof JL, Saidman LJ, et a1 Laparoscopic sterilization with local anesthesia: Complications and blood gas changes. Anesth Analg 56335, 1977

12. Edelman D S Laparoscopic cholecystectomy under continuous epidural anesthesia in patients with cystic fibrosis. Am J Dis Child 145:723, 1991


13. Freidman IH, Grossman MB, Wolff W. The value of laparoscopy in general surgical problems. Surg Gynecol Obstet 144:906, 1977

14. Haldane G, Stott S, McMenemin I: Pouch of Douglas block for laparoscopic sterilization. Anesthesia 53:589, 1998

15. Hall TJ, Donaldson DR, Brennan T G The value of laparoscopy under local anesthesia in 250 medical and surgical patients. Br J Surg 67751, 1980

16. Hatasaka HH, Sharp HT, Dowling DD: Laparoscopic tubal ligation in a minimally invasive surgical unit under local anesthesia compared to a conventional operating room approach under general anesthesia. J Laparoendosc Adv Surg Tech A 7295,1997

17. Johannsen G, Andersen M, Juhl B: The effect of general anesthesia on the hemodynamic events during laparoscopy with C02 insufflation. Acta Anesthesiol Scand 33:132,1989

18. Kuster GG, Gilroy SB: The role of laparoscopy in the diagnosis of acute appendicitis. Am Surg 58:627, 1992

19. Lewin A, Margalioth EJ, Rabinowitz R Comparative study of ultrasonically guided percutaneous aspiration with local anesthesia and laparoscopic aspiration of follicles in an in vitro fertilization program. Am J Obstet Gynecol 151:621, 1985

20. Liu SS Optimizing spinal anesthesia for ambulatory surgery. Reg Anesth 22:500, 1997 21. Milki AA, Tazuke SI Office laparoscopy under local anesthesia for gamete intrafallop-

ian transfer: Technique and tolerance. Fertil Steril 68:128, 1997 22. Miller G H Office single puncture laparoscopy sterilization with local anesthesia. J SOC

Laparoendosc Surg 1:55,1997 23. Pattinson RC, Louw NS, Engelbrecht B, et al: Complications in 8509 laparoscopic

Falope ring sterilizations performed under local anaesthesia. S Afr Med J M975, 1983 24. Pelland PC: The application of lidocaine to the fallopian tubes during tubal fulguration

by laparoscopy. Obstet Gynecol47501, 1976 25. Penfiild AJ: Laparoscopii sterilization under local anesthesia: 1200 cases. Obstet Gyne-

col49:725, 1977 26. Peterson HB, Hulka JF, Spielman FJ: Local versus general anesthesia for laparoscopic

sterilization: A randomized study. Obstet Gynecol 70:903, 1987 27. Poindexter AN, Abdul-Malak M, Fast JE: Laparoscopic tubal sterilization under local

anesthesia. Obstet Gynecol 75:5, 1990 28. Puri GD, Singh H: Ventilatory effects of laparoscopy under general anesthesia. Br J

Anesth 68:211, 1992 29. Salvino CK, Esposito TJ, Marshall WJ, et al: The role of diagnostic laparoscopy in the

management of trauma patients: A preliminary assessment. J Trauma X513, 1993 30. Schulman JD, Dorfmann AD, Jones SL: Outpatient in vitro fertilization using transvagi-

nal ultrasound guided oocyte retrieval. Obstet Gynecol 69:665, 1987 31. Silva PD, Kang SB, Sloane KA: Gamete intrafallopian transfer with spinal anesthesia.

Fertil Steril 59:841, 1993 32. Smith BE, MacPherson GH, de Jonge M: Rectus sheath and mesosalpinx block for

laparoscopic sterilization. Anaesthesia 10875, 1991 33. Smith BE, Suchak M, Siggins D, et al: Rectus sheath block for diagnostic laparoscopy.

Anaesthesia 43:947, 1988 34. Solylo MA, Vaghadia H, Henderson C, et al: Walk-in/walk-out spinal anesthesia for

laparoscopy: Return of spinal cord function. Can J Anesth 4639, 1999 35. Spielman FJ. Laparoscopic surgery. In Hood DD (ed): Problems in Anesthesia: Anesthe-

sia in Obstetrics and Gynecology. Philadelphia, JB Lippincott, 1989, p 151 36. Spielman FJ, Hulka JF, Ostheimer GW Pharmacokinetics and pharmacodynamics of

local analgesia for laparoscopic tubal ligations. Am J Obstet Gynecol 146:821, 1983 37. Spivak H, Nudelman I, Fuco V, et al: Laparoscopic extraperitoneal inguinal hernia

repair with spinal anesthesia and nitrous oxide insufflation. Surg Endosc 10:1026,1999 38. Steege J F Superior hypogastric block during microlaparoscopic pain mapping. J Am

Assoc Gynecol Laparosc 6:51, 1999 39. Stewart A, Collins L, Vaghadia H, et al: Walk-in/walk-out spinal anesthesia results in

earlier fast track eligibility compared to propofol general anesthesia [abstr]. In Pro- grams and Abstracts of the World Congress of Anesthesia, Montreal, World Congress 2000

40. Tobias JD, Holcomb GW, Brock JW, et a1 Analgesia after inguinal hemiorrhaphy with


laparoscopic inspection of peritonem in children: Caudal block versus ilioinguinal/ iliohypogastric block. Am J Anesthesiol 22193, 1995

41. Tobias JD, Holcomb GW, Lowe s, et al: Caudal epidural block for analgesia following hemiorrhaphy with laparoscopy in children. J Laparoendosc Surg 4:117, 1994

42. Tope1 HC: Gasless laparoscopy under epidural anesthesia in a woman with a 14-week gestation. J Am Assoc Gynecol Laparosc 2(suppl4):79,1995

43. Vaghadia H, McLeod DH, Mitchell GW Small-dose hypobaric lidocaine-fentanyl spinal anesthesia for short duration outpatient laparoscopy, I. A randomized comparison with conventional dose hyperbaric lidocaine. Anesth Analg 84:59, 1997

44. Vaghadia H: Spinal anesthesia for outpatients: Controversies and new techniques. Can J Anesth 4564, l998

45. Van EE R, Hemrika DJ, De Blok S Effects of ketoprofen and mesosalpinx infiltration on postoperative pain after laparoscopic sterilization. Obstet Gynecol 88:568, 1996

46. Viskari D, Berrill A, Vaghadia H Walk-in/walk-out spinal anaesthesia for outpatient laparoscopy: Evaluation of three hypobaric solutions. Can J Anaesth 44A26-8, 1997

47. Wall RT, Gelmann EP, Hahn MB: Monitored anesthesia care for laparoscopies in oncology patients. Anesthesiol Rev 1843, 1991

48. Waterstone JJ, Boulton VN, Wren M Laparoscopic zygote intrafallopian transfer using augmented local anesthesia. Fertil Steril 57442, 1992

49. Wilcox S, Vandam LD Alas, poor Trendelenburg and his position! A critique of its uses and effectiveness. Anesth Analg 76:574, 1988

50. Zupi E, Sbracia M, Marconi D: Pain mapping during minilaparoscopy in infertile patients without pathology. J Am Assoc Gynecol Laparosc 6:51, 1999

Address reprint requests to Himat Vaghadia, MD, MB, BS, FRCPC

Department of Anesthesia Vancouver Hospital and Health Science Center

910 West 10th Avenue Vancouver, BC

Canada V5Z4E3

e-mail: [email protected]

regional anesthesia for laparoscopy

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