Since the inception of Laparoscopic Cholecystectomy by Philipe Mouret in 1987, General Anesthesia as Anesthetic procedure of choice has been in vogue [1,2]. General Anesthesia with controlled ventilation is advocated to avoid aspiration, pneumoperitoneum induced hypercapnia, respiratory and abdominal discomfort [3]. Albiet neuraxial anesthesia has been utilized for diagnostic laparoscopy, it has not been entrusted for routine laparoscopic surgeries and its use is restricted only for the patients where general anesthesia is venturesome owing to compromised respiratory status [4]. Van Zundert conducted a feasibility study of segmental Spinal Anesthesia for Laparoscopic Cholecystectomies in healthy individuals [5]. Spinal Anesthesia offers distinct advantage in terms of reduced incidence of PONV (Post Operative Nausea and Vomiting), decreased Post Operative pain, early ambulization and more awake and oriented patients at conclusion of surgery [6,7,8]. In another study, Spinal Anesthesia showed hemodynamic stability comparable to general anesthesia but with reduced neuro-endocrine stress response [3,9]. Recently increased number of geriatric and high risk patients are subjected to Laparoscopic surgeries where regional anesthesia offers

above enlisted advantages along with increased patient satisfaction [3,10-13]. Owing to paucity of studies comparing Spinal Anesthesia with General Anesthesia for Laparoscopic Surgeries, we proposed this study to compare the effectiveness of General Anesthesia versus Spinal Anesthesia in terms of Patient’s and Surgeon’s satisfaction, post operative hospitalization and cost effectiveness.

After obtaining approval from Institutional Ethical Committee, the present study was conducted on 50 ASA grade I & II patients of either sex and age group 18-60 years for undergoing laproscopic cholecystectomy, in department of Anesthesia at Santosh Medical College & Hospital, Ghaziabad. The day before surgery, all the patients were examined and thoroughly investigated and complete preoperative evaluation done, operative and postoperative vital parameters were recorded. Patients having bleeding diathesis, on any anticoagulant therapy, hypersensitivity to local anesthetics or study drugs, history of drug abuse, mentally retarded, cardio respiratory, renal, hepatic and CNS disorders were excluded from this study. After obtaining informed consent, the patients were randomly allocated to two groups of 25 each; Group I; received general anaesthesia, Group II; received spinal anesthesia. In the operation theatre intravenous line with Ringer lactate was started and all patients in both the groups were preloaded at rate of 10 ml/kg over 15-20 minutes. Reading of heart rate, blood pressure, electrocardiogram & peripheral arterial oxygen saturation measured were taken as base line parameters. In group I patients received spinal anesthesia at L2-L3 intervertebral space using 25 G spinal needle with 3 ml of 0.5% bupivacaine heavy with 25mg tramadol as bolus dose. Patients were turned supine and oxygen with ventimask at flow rate of 4 liters/min was started and after the block gets fixed; the level of sensory and motor block was checked. Operation was started after full surgical anesthesia. On feeling shoulder tip pain spinal anesthesia was converted to general anesthesia. In Group II general anesthesia was given to the patients who were premedicated with Inj butorphanol intravenously (1mg) and Inj glycopyrrolate (0.01mg/ kg). After preoxygenation with 100% oxygen for 3 minutes, induction was done with propofol 2mg/kg body weight intravenously and tracheal intubation facilitated with Inj vecuronium bromide 0.1mg/kg intravenously, halothane in combination with N2 O and oxygen. Anesthesia was maintained with nondepolarizing muscle relaxant Inj vecuronium 0.05mg/kg iv and was repeated if needed. Oropharyngeal suction was done, Inj neostigmine (0.05mg/kg) and Inj glycopyrrolate (0.01mg/kg) were given intravenously to reverse the neuromuscular blockage. Patients were shifted to recovery room when fully conscious with normal vitals and normal reflexes. At the end of surgery pain score was analyzed with VAS and injection diclofenac 75mg was given when VAS score was more than 4. Vitals were checked at regular intervals in both the groups.

Statistical Analysis

Study was statistically analyzed using student t test for heart rate, systolic blood pressure, diastolic blood pressure, respiratory rate, SpO2 . Nausea, vomiting, pruritis, respiratory depression, abdominal pain, chest wall rigidity, shoulder tip pain, sedation were analyzed using chi square test and ANOVA was used to analyze age, weight, duration of surgery and fluid requirement.

Table Characteristics of patients in group I & II

Group I – Spinal Anaesthesia, Group II-General Anaesthesia Data is Mean ± S.D NS – Non-significant (p>0.05) There were no significant differences in age, weight, gender and duration of surgery between the three groups.

The patients who received spinal anesthesia (group I) had decreased hemodynamic variables such as pulse rate and blood pressure with 7 patients requiring mephentermine and 11 patients requiring atropine. The SpO2 and respiratory rate remained stable throughout the surgery. Postoperatively, the vitals were stable. Postoperatively side effects like nausea were present in 13 patients and urinary retention in 4 patients. VAS score in the postoperative period remained low for the initial 2 hours. The postoperative analgesia was required after 2 hours with a mean dose requirement of 1.48 ( Number of analgesic doses) in the first postoperative day.

Table 2: Side effects in group I & II

Group I – Spinal Anesthesia, Group II-General Anesthesia

NS – Non-significant (p>0.05), HS- Highly significant (p<0.001)

In the patients who received general anesthesia (group II), hemodynamic variable such as pulse rate, respiratory rate and SpO2 remained stable throughout the surgery and there was decrease in blood pressure only in 1 patient. Postoperatively, the vitals remained stable. Postoperative side effects like nausea were present in 11 patients, urinary retention in 2 patients and vomiting in one patient. The VAS score was found to be high (VAS>4) and the analgesic dose was given immediately after the surgery with the mean dose requirement of 2.56 (Number of analgesic doses) throughout the first postoperative day.

Cholecystectomy is the surgical removal of the gall bladder. The choice of anesthesia for patients posted for cholecystectomy is a well-planned balanced general anesthesia using appropriate amount of muscle relaxant, intravenous narcotics and controlled ventilaton; Regional anesthesia for laproscopic cholecystectomies has also been reported in some cases [14]. These observations of laproscopic cholecystectomies conducted under both General as well as Regional Anaesthesia prompted us to evaluate the Comparative efficacy of General Anaesthesia versus Spinal Anaesthesia for Laproscopic Cholecystectomies. There was decrease in heart rate in group I from baseline which was statistically significant immediately after administration of spinal anesthesia coinciding with the effect of intrathecal bupivacaine and tramadol. Pursnani et al performed laparoscopic cholecystectomy on 6 patients with chronic respiratory disease under regional anesthesia. They found no significant change in heart rate throughout the surgery. We hypothesize that the decrease in our study may be attributed to the effect of tramadol [15]. Group I showed significant reduction in blood pressure throughout the surgery which becomes insignificant towards the end of the surgery coinciding with the weaning effect of the spinal anesthesia. In a study conducted by Kohki N et al for comparison of intravenous and regional anesthesia in 30 elderly patients undergoing laparoscopic cholecystectomy, a fall in intraoperative blood pressure in 27% patients was noticed. This finding is consistent with the findings in our study where 28% patients presented with hypotension [16]. The mean change in SpO2 in group I and II were statistically significant but clinically not significant. The SpO2 did not fall below 95% in any group in the intraoperative as well as in postoperative period. Pursnani K.G. et al in their study on laparoscopic cholecystectomy under epidural anesthesia in patients with chronic respiratory disease also observed that there was no change in SpO2 in intraoperative or postoperative period [15]. Our study showed that postoperative analgesia in group I was comparable and better than the patients of group II. This decreased pain was mainly during the first two hours after the procedure, most likely due to presence of an adequate level of analgesia in the early postoperative hours due to presence of narcotic & local anesthetic drug near spinal cord [17].

To conclude, we found that both the techniques are effective with their own merits and demerits. From surgeon’s perspective and in view of intraoperative discomfort to the patient attributable to pneumoperitoneum, General Anesthesia is a better choice for laparoscopic cholecystectomy. Nevertheless in respiratory compromised patients, Spinal Anesthesia is a better choice because of reduction in chances of patient landing up into Intensive Care Unit for ventilatory support which may prolong hospital stay and cost.

1. Vccchio R, MacFayden BV, Palazzo F. History of laparoscopic surgery. Panminerva Med 2000;42:87-90.
2. Spaner SJ. Warnock GL. A brief history of endoscopy, laparoscopy, and laparoscopicsurgery. J Laparoendose Adv Surg Tech A 1997;7:369-73.
3. Pursnani KG, Bazza Y, Calleja M, Mughal MM. Laproscopic cholecystectomy under epidural anaesthesia in patients with chronic respiratory disease. Surg Endosc 1998;12:1082-84.
4. D Writuparna, B Susmita, G Sarmila, S Swarnamukul, M Suchismita, P Saswati. Comparison between general anesthesia and spinal anesthesia in attenuation of stress response in laparoscopic cholecystectomy: A randomized prospective trial 2015-ncbi.nlm.nih.gov.
5. Van zundert AA, Stultiens G, Jakimowicz JJ, Peek D, Ham van der, Korsten HHM et al.Laproscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth 2007;98(5):682-86.
6. Bessa SS, Katri KM, Abdel-Salam WN, El-Kayal el-SA, Tawfik TA. Spinal versus general anesthesia for day-case laparoscopic cholecystectomy: A prospective randomized study. J Laparoendosc Adv Surg Tech A. 2012;22:550-5.
7. Lennox PH, Chilvers C, Vaghadia H. Selective spinal anesthesia versus desflurane anesthesia in short duration outpatient gynecological laparoscopy: A pharmacoeconomic comparison. Anesth Analg. 2002;94:565-8.
8. Yukesk YN, Akat AZ, Gozalan U, Daglar G, Pala Y, Canturk M, et al. Laparoscopic Cholecystectomy under spinal anaesthesia. Am J Surg. 2008;195:533-6.
9. Aono H, Takeda A, Tarver SD, Goto H. Stress responses in three different anesthetic techniques for carbon dioxide laparoscopic cholecystectomy. J Clin Anesth. 1998;10: 546-50.
10. Gramatica L Jr, Brasesco OE, Luna AM. Laparoscopic cholecystectomy performed under regional anaesthesia in patients with chronic obstructive pulmonary disease. Surg Endosc 2002;16:472-75.
11. Tzovaras G. Fafoulakis F, Pratsas K, Georgopoulou S. Stamatiou G. Hatzitheofilous C. Laparoscopic cholecystectomy under spinal anesthesia: A pilot study. Surg Endosc 2006;20:580-2.
12. Kim YI. Lec JS. Jin HC, Chae WS, Kim SH. Thoracic epidural anesthesia for laparoscopic cholecystectomy in elderly patient with severely impaired pulmonary function tests. Acta Anaesthesiol Scand 2007;51:1394-6.
13. Savas JF, Litwack R, Davis K, Miller TA. Regional anaesthesia as an alternative to general anesthesia for abdominal surgery in patients with severe pulmonary impairment. Am I Surg. 2004;188:603-5.
14. Abboud TK, Moore M, Zhu J, Murakawa K, Minehart M, Longhitano M etal. Epidural butorphanol or morphine for the relief of post-cesarean section pain:ventilatory responses to carbon dioxide. Anesth Analg 1987;66:887-93.
15. Sood Jayashree, Kumar VP. Anaesthesia for laproscopic surgery.Ind J Surg 2003;65(3):232-40.
16. Schuricht, Alan L, McCarthy, Cindy S, Wells, Wendi L et al. A comparison of epidural versus general anaesthesia for outpatient endoscopic preperitoneal herniorraphy. J Soc Lap Surg 1997;1(2):141-44.
17. Van Zundert AAJ, Stultiens G, Jakimowicz JJ, Van den Borne BEEM, Van der Ham WGJM, Wildsmith JAW. Segmental spinal anesthesia for cholecystectomy in a patient with severe lung disease. BJA 2006;96(4):464-66.