Background and Objectives: Spinal anaesthesia was combined with general anaesthesia for achieving hemodynamic stability in laparoscopic hysterectomy. The aim of our study was to evaluate the impact of SA combined with GA in maintaining hemodynamic stability in laparoscopic hysterectomy. The secondary outcomes studied were requirement of inhaled anaesthetics, vasodilators.

Material and Methods: We conducted a prospective randomized study in ASAI/II patients posted for laparoscopic hysterectomy, after taking proper written consent. Patients were randomly assigned to receive SA with GA (group SGA) or plain GA (group GA).Group SGA received 10 mg of 0.5% Bupivacaine (heavy) for SA. GA was administerd using conventional balanced technique. Maintenance was carried out with nitrous oxide, oxygen, and isoflurane. Comparison of hemodynamic parameters was carried out during creation of pneumoperitoneum and thereafter. Total isoflurane requirement, need of vasodilators and surgeon satisfaction were also studied.

Results: Patients in group SGA maintained stable and acceptable MAP values throughout pneumoperitoneum. The difference as compared to GA was statistically significant (p<0.01). Group GA showed additional requirement of Nitroglycerine infusion and higher concentration of isoflourane. Group SGA showed greater surgeon satisfaction as compared to group GA.

Conclusion: The hemodynamic repercussions during pneumoperitoneum can be effectively attenuated by combining SA and GA, without any adverse effects.

Keywords: General anaesthesia, hemodynamics, laparoscopy, pneumoperitoneum, spinal anaesthesia.

1. Harrell AG, Lincourt AE, Novitsky YW, et al. Advantages of laparoscopic appendectomy in the elderly. Am Surg. 2006;72:474e480.
2. Hendolin HI, Paakonen ME, Alhava EM, Tarvainen R, Kemppinen T, Lahtinen P. Laparoscopic or open cholecystectomy: a prospective randomised trial to compare postoperative pain, pulmonary function and stress response. Eur J Surg. 2000;166:394e399.
3. Zacks SL, Sandler RS, Rutledge R, Brown Jr RS. A population based cohort study comparing laparoscopic cholecystectomy and open cholecystectomy. Am J Gastroenterol. 2002;97:334e340.
4. Chui PT, Gin T, Oh TE. Anaesthesia for laparoscopic general surgery. Anaesth Intensive Care. 1993;21:163e171.
5. Gerges FJ, Kanazi GE, Jabbour-Khoury SI. Anesthesia for laparoscopy: a Review. J Clin Anesth. 2006;18:67e78.
6. Collins LM, Vaghadia H. Regional anaesthesia for laparoscopy. Anesthesiol Clin N Am. 2001;19:43e55.
7. Van Zundert AA, Stultiens G, Jakimowicz JJ, et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study. Br J Anaesth. 2007;98:682e686.
8. Gramatica L, Brasesco OE, Luna AM, et al. Laparoscopic cholecystectomy performed under regional anesthesia in patients with chronic obstructive pulmonary disease. Surg Endosc. 2002;16:472e475.
9. Pursnani KG, Bazza Y, Calleja M, Mughal MM. Laparoscopic cholecystectomy under epidural anesthesia in patients with chronic respiratory disease. Surg Endosc. 1998;12: 1426e1428.
10. Chowbey PK, Sood J, Vashistha A, et al. Extraperitoneal endoscopic groin hernia repair under epidural anesthesia. Surg Laparosc Endosc Percutan Tech. 2003;13:185e190.
11. Sulemanji DS, Donmez A, Arslan G. Epidural anaesthesia for laparoscopic cholecystectomy in a patient with scleroderma. Br J Anaesth. 2006;97:749.
12. Tiwari S, Chauhan A, Chaterjee P, Alam M. Laparoscopic cholecystectomy under spinal anaesthesia: a prospective, randomised study. J Minimal Access Surg. 2013;2(9):65e71.
13. Vretzakis G, Bareka M, Aretha D, Karanikolas M. Regional anesthesia for laparoscopic surgery: a narrative review. J Anesth. 2014;28(3):429e446.
14. Kar M, Kar JK, Debnath B. Experience of laparoscopic cholecystectomy under spinal anesthesia with low-pressure pneumoperit-oneume prospective study of 300 cases. Saudi J Gastroenterol. 2011;17:203e207.
15. Pratsas K, Georgopoulou S, Bareka M, Ieropoulos C, Flossos A, Vretzakis G. The feasibility of laparoscopic general surgery under regional Anaesthesia. Greek E-J Perioper Med.2010;8:1e10.
16. Mane RS, Patil MC, Kedareshvara KS, Sanikop CS. Combined spinal epidural anesthesia for laparoscopic appendectomy in adults: a case series. Saudi J Anaesth. 2012;6:27e30.
17. Odeberg S, Ljungquist O, Svenberg T, Gannedahl P, Bäckdahl M, von Rosen A, et al. Hemodynamic effects of pneumoperitoneum and the influence of posture during anesthesia for laparoscopic surgery. Acta A naesthesiol Scand. 1994;38:276–83.
18. Safran DB, Orlando R. Physiological effects of pneumoperitoneum. Am J Surg. 1994; 167:281–6.
19. Joris J, Lamy M. Neuroendocrine changes during pneumoperitoneum for laparoscopic cholecystectomy. Br J Anaesth. 1993;70:A33.
20. Feig BW, Berger DH, Doughtery TB, Dupuis JF, His B, Hickey RC, et al. Pharmacological intervention can reestablish baseline haemodynamic parameters during laparoscopy.  Surgery. 1994;116:733–9.
21. Luchetti M, Palomba R, Sica G, Massa G, Tufano R. Effectiveness and safety of combined epidural and general anesthesia for laparoscopic cholecystectomy. Reg Anesth. 1996;21:465–9.
22. Lehtinen AM, Laatikainen T, Koskimies AI, Hovorka J. Modifying effects of epidural analgesia or general anesthesia on stress hormone response to laparoscopy for in vitroJ In Vitro Fert Embryo Transf. 1987;4:23–9.
23. Lerou JG, Booij LH. Model based administration of inhalational anesthesia. Developing a system model. Br J Anaesth. 2001;86:12–28.
24. Liu SS, Carpenter RL, Mackey DC, Thirlby RC, Rupp SM, Shine TS, et al. Effects of perioperative analgesic technique on rate of recovery after colon surgery.  Anesthesiology. 1995;83:757–65. 

Subhadipta Panigrahi

Junior Resident, Department of Anaesthesiology, VIMSAR