ANESTHESIA FOR DIAGNOSTIC AND OPERATIVE LAPAROSCOPY

Transcription

1 FERTILITY AND STERILITY 1971 by The Williams & Wilkins Co. Vol. 22, No. 10, October 1971 Printed in U.S.A. ANESTHESIA FOR DIAGNOSTIC AND OPERATIVE LAPAROSCOPY CLIFFORD R. WHEELESS, JR., M.D. Department of Gynecology and Obstetrics, The Johns Hopkins Hospital, Baltimore, Maryland 690 The revival of the surgical procedure of laparoscopy has obtained the interest of gynecologists from all parts of the United States and abroad. 1, 2 The motivation behind the revival of this procedure has centered around the problem of bed utilization, rising hospital costs, and the desire of the modern woman to remain in the hospital for the shortest period of time. A current problem for the average practitioner is the ancient argument of laparoscopy vs. culdoscopy. 1 This argument has centered around the discussion that culdoscopy can be done under local anesthesia, whereas laparoscopy requires general anesthesia and, thus, places the patient at greater risks and is more involved for hospital and physician. 1-3 The Gynecological Service at The Johns Hopkins Hospital has performed over 1000 diagnostic and operative laparoscopies between the years The purpose of this review is to outline our experience with two forms of pain relief in diagnostic and operative outpatient laparoscopy. This study was undertaken, not because of problems with outpatient general anesthesia or associated anesthesia morbidity in the Outpatient Gynecological Surgery Clinic at the Johns Hopkins Hospital (for minor outpatient gynecologic procedures have been performed under general anesthesia for 30 years on more than 90,000 patients), but to assess the efficacy of laparoscopy under local anesthesia for those clinics having problems obtaining outpatient general anesthesia services. We have performed outpatient laparoscope sterilization under general anesthesia on over 900 cases with no anesthetic deaths and no anesthesia morbidity. We find that our colleagues in other centers around the country have had difficulty with their local anesthesia departments in authorizing outpatient surgical procedures under general anesthesia. Thus, these centers were faced with the problem of doing outpatient culdoscopy under localor admitting the patient for 3 days to do laparoscopy under general anesthesia. We can find no evidence in the literature, or from our own experience, that this policy is necessary or justified. 3, 8, 9 Therefore, this study was undertaken to evaluate laparoscopy under local anesthesia and systemic analgesia in 50 outpatient laparoscope sterilizations as to patient reaction, pain, ease of surgical technic, and patient evaluation postoperatively. MATERIALS AND METHODS Fifty patients were selected from the Outpatient Laparoscope Sterilization Clinic at random and were offered sterilization under local anesthesia. When the procedure was adequately explained, only 5 patients refused local anesthesia and demanded general anesthesia. The patients ranged in age from years. Racial distribution was 50% Negro and 50% Caucasian. Parity ranged from 1-9 children. Weight distribution was 105 Ib.-250 lb., with a mean of 155 lb. Seventeen per cent of the patients had undergone previous abdominal surgery. Outpatients had the procedure of laparoscope sterilization thoroughly explained and were told that they would not be asleep, that they would

2 . October 1971 LAPAROSCOPY 691, ' J r feel abdominal manipulation, but would experience little, if any, pain. Analgesia and anesthesia were administered as follows. Thirty minutes prior to the operation, the patient was given 0.5 mg. of atropine intramuscularly. The patient assumed the dorsal supine position on the operating table. Analgesia was provided. with 100 mg. of meperidine (Demerol) and 10 mg. of Valium (diazepam). This solution was injected intravenously over a 2-min. period. The analgesic injection was accomplished while the surgeons were scrubbing. The patient was then told step-by-step each part of the procedure before it took place. The majority, 35 out of 50 patients, were quite sleepy as the skin was being prepped in the periumbilical area. After the patient was prepped, she was placed in the modified lithotomy position, a Simm's speculum was gently placed in the vagina, the anterior lip of the cervix was grasped with a Jacob's tenaculum, a Rubin's cannula was inserted into the endocervical canal, and connected to the Jacob's tenaculum. Care was taken at all times for movements to be gentle and slow. Surgical drapes were then applied and the periumbilical area was injected with 1.5% of Xylocaine from 10-2 o'clock on the umbilicus. This injection generally required cc. and was carried down to and included the fascia and peritoneum. After the injection of Xylocaine, two towel clips were applied on the lateral rims of the umbilicus at 3 and 9 o'clock. A 2-mm. skin incision was made in the inferior rim of the umbilicus. A 16-gauge Thoey needle was inserted through this incision into the peritoneal cavity. The carbon dioxide gas hose was connected to the WISAP (Eder Instrument Company, Chicago, TIL) (Semm) pneumoperitoneum insufflator machine and strict attention was paid to the insufflation pressure. As long as the insufflation pressure was below 20 mm. of mercury on the machine, we were confident that we were in the peritoneal cavity and not injecting.the gas into the subcutaneous, subfascia, or omental spaces. If the pressure on insufflation rose above 20 mm. of mercury, the tip of the needle was presumed to be in the wrong space and it was repositioned. When L of carbon dioxide had been insufflated into the peritoneal cavity at a flow rate of 1 L/min, the needle was withdrawn. The 2-mm. incision in the inferior rim of the umbilicus was then extended to 1 cm. and the laparoscope trocar and sleeve were pushed through the incision while holding up on the two towel clips on the lateral rims of the incision. The operating laparoscope (Fig. 1) was then inserted through the trocar sleeve and the pelvis thoroughly inspected. 7 This inspection was aided by the use of Jacob's tenaculum and Rubin's cannula previously placed on the cervix. The electrocoagulation forcep was introduced through the operating laparoscope and the fallopian tubes were grasped and burned with the cutting current of the electrocoagulator (Fig. 2). After 6-8 sec. of electrocoagulation using the cutting current, a small piece of tube was removed. 4-7 The same procedure was performed on the other side. The operating laparoscope was withdrawn and the incision was closed with a 4 Chromic catgut suture subcuticularly. A Band-Aid was applied. The patient was removed to the recovery room for observation for 2-3 hr. and discharged home. 6 All patients were given a prescription for Darvon compound upon discharge. Patients were asked to return for a 4-week postoperative check-up. Postoperative hysterograms were not performed because of the results from the series previously reported from this institution. 5 The hysterogram diagnostic procedure was felt to be costly, time consuming, and unnecessary. Postoperatively, all patients were placed in the Recovery Room where they were

3 692 WHEELESS Vol. 22,. FIG. 1. Photograph of operating fiberoptic laparoscope with electrocoagulation forcep inserted. monitored for vital signs, vaginal and abdominal bleeding, and an attempt was made to assess their level of postoperative pain. RESULTS All 50 patients had laparoscope sterilization completed under local anesthesia and systemic analgesia. In 5 of the patients, difficulty was experienced by movement of the patients on the operating table. In 1 of these 5, movement was secondary to genuine discomfort as the patient had severe liver disease and could not tolerate even small doses of narcotics. Therefore, she was operated upon under pure local anesthesia. The remaining 4 patients in this group experienced movement unrelated to painful stimuli and resembled the movement and verbalization frequently witnessed in obstetrical patients given heavy intravenous analgesia in labor. All 50 patients noted some minor degree of discomfort at the time the electrocoagulator was turned on the fallopian tube. In no case was this enough to discontinue the procedure. The pain expressed was similar to that noted during cervical biopsy. The immediate postoperative recovery in all 50 patients was uneventful. Several attempts were made by unbiased observers to select those patients in the recovery room who had been operated upon under local, compared to those patients in the same recovery room, who had been operated upon under general anesthesia. No differences could be noted. All patients were discharged at the usual time, 3-4 hr. postoperatively. Those patients operated upon under local anesthesia and systemic analgesia appeared more sedated upon discharge than the group who had had general anesthesia. All patients were interviewed at the 4-week postoperative check-up. There appeared to be no difference in their recovery time between the group operated upon under general anesthesia and the group operated upon under local anesthesia with systemic analgesia. Postoperative pain 1-4 days following surgery was easily controlled in both groups with Darvon compound. Postoperative interviews revealed that most women compared the amount of discomfort as compatible with moderate to severe menstrual cramps.

4 October 1971 LAPAROSCOPY 693 DISCUSSION Unfortunately, quality, knowledgeable anesthesia is a contemporary phenomenon in American surgery. There are still areas of the country where anesthesia, and particularly gynecologic and obstetrical anesthesia, is performed by practitioners with less than the optimal training that exists in more sophisticated centers. Because of this phenomenon, rules and regulations have been required that, in some cases, have been substituted for knowledge of respiratory physiology, cardiovascular tolerance of barbiturates, and insufficient numbers of qualified anesthesiologists administering anesthesia. From our experience in this clinic, we can see no scientific evidence why general anesthesia cannot be performed on an outpatient basis on large numbers of pa_ tients reqmrmg minor surgery, providing the patients have been preoperatively screened for medical diseases. There is no question that even the most elaborate surgical procedure such as cholecystectomy, vaginal or abdominal hysterectomy, and craniotomy can be performed under local anesthesia. It is also increasingly apparent that with the application of modem anesthesia technics administered by competent anesthesiologists general anesthesia is safer than local anesthesia in many cases, including pa_ tients with severe cardiovascular respiratory problems. This is secondary to the fact that local anesthesia rarely produces complete pain relief and such pain stimuli can produce vasovegal responses causing cardiac arrhythmias at an incidence greater than that produced by induction under general anesthesia. FIG. 2. Drawing of operating fiberoptic laparoscope with electrocoagulation forcep inserted through the umbilicus.

5 694 WHEELESS Vol. 22 Reviewing the experience of 30 years of outpatient general anesthesia for minor gynecologic cases, we were impressed with the fact that general anesthesia was safe and gave better surgical results than local anesthesia with systemic analgesia. However, there is little doubt that operative laparoscopy can be performed, under local anesthesia with systemic analgesia, safely and adequately. Therefore, the decision to use culdoscopy or laparoscopy must be based. on other criteria than the modality of pain relief. SUMMARY Proper anesthesia for diagnostic and operative laparoscopy is a controversial subject. The object of this paper was to evaluate laparoscope tubal sterilization under local anesthesia and systemic analgesia. Acknowledgment. Appreciation is expressed to Henry S. Lim, M.D., Department of Anesthesiology (Women's Clinic Section), The Johns Hopkins Hospital, Baltimore, Md. REFERENCES 1. COHEN, M. R. Laparoscopy, Culdoscopy and Gynecography Technique and Atlas. Saunders, Philadelphia, 1970, pp STEPrOE, P. C. Laparoscopy in Gynecology. Livingstone, London, 1967, pp BoLGLA, J. H. Anesthesia for Pelvic Laparoscopy (Vol. I), Cohen, M. R., Ed. Saunders, Philadelphia, 1970, pp THOMPSON, B., AND WHEELESS, C. R. Outpatient sterilization by laparoscopy-a report-of 666 cases. Obstet Gynec. To be published. 5. WHEELESS, C. R. A rapid, inexpensive, and effective method of surgical sterilization by laparoscopy. Reprod Med 5:255, WHEELESS, C. R. Outpatient tubal sterilization. Obstet Gynec 36:208, WHEELESS, C. R. Elimination of the second incision in laparoscope sterilization. Obstet Gynec. To be published. 8. BoNICA, J. J. Regional anesthesia in private practice. Anesthesiology 21 :554, GoLDSTEIN, A., JR., AND KEATS, A. S. Risk of anesthesia. Anesthesiology 33:130, 1970.