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Author Topic: laproscopic cholecystectomy under spinal anesthesia  (Read 2424 times)

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tushararya

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laproscopic cholecystectomy under spinal anesthesia
« on: April 05, 2010, 04:53:36 AM »
I have been conducting lap Cholycystectomies under spinal anesthesia for quite some time now. I find a little bit of reassurance and fentanyl at 1 microgm/kg is usually sufficient to take care of shoulder pain.
I would like to know
1. medicolegal responsibility of this
2. What experiences have others met with in this procedure. 
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anaesami

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Re: laproscopic cholecystectomy under spinal anesthesia
« Reply #1 on: April 14, 2010, 02:13:24 AM »
if anything goes wrong during lap choly, you may be blamed for selecting spinal anaesthesia for the procedure. your method would not pass the "bolam's test'. you may not find experts to support your technique.
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yogenbhatt1

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Re: laproscopic cholecystectomy under spinal anesthesia
« Reply #2 on: April 19, 2010, 02:10:04 PM »
HI,
DOING A LAP SURGERY UNDER REGIONAL IS NOT NEW OR UNUSUAL. MANY DOCTORS PRACTICE IT.
AS YOU ARE  IN THE CITIES AND MAJOR TOWNS, MORE GA CASES ARE PERFORMED. BUT AS YOU GO INTERIORS, THE REGIONAL PRACTICE IS QUITE COMMON. ( PURELY MY OPINION, MANY MAY STRONGLY OBJECT AND RIGHTLY)
IT IS NEED BASED. COSTINGS INVOLVED, RISK, SMALLER SETUPS, LESS QUALIFIED MANPOWER, UNAVAILABILITY OF DRUGS AND MATERIALS, ??? POST OP MONITORING IN HIGH RISK CASES, AND SO ON.
I DO NOT SAY THAT THEY WILL DO A SUBSTANDARD JOB OR SOMETHING THAT IS NOT RECOMMENDED. THE AVAILABILITY OF ANASTHESIOLOGIST IS SO LESS, THAT IT BECOMES NEED OF THE HOUR.
HERE SURGEONS TOO BECOME VERY ADJUSTABLE AND FAST TOO.
ALL THIS CONSIDERED DOING A LAP SURGERY UNDER SPINAL IS JUSTIFIED.
WE HAVE TRIED OUT DOING CASES UNDER REGIONAL, AND GIVEN UP, AS WE NEVER ENJOYED IT. BUT IT CAN BE DONE.
LEGALITIES ARE TO BE THOUGHT OF. NO TEXT BOOK, AS TO MY KNOWLEDGE, TELLS THAT ALL LAP SURGERIES ARE TO BE DONE UNDER GENERAL ANAESTHESIA. AS FAR AS LAW IS CONCERNED, AS LONG AS YOU CAN PROVIDE REFERENCES TO THEM, THEY ARE FINE.
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jafo1964

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Re: laproscopic cholecystectomy under spinal anesthesia
« Reply #3 on: May 01, 2010, 06:31:11 PM »
I think we already had a thread on this site regarding RA for laproscopic surgery.

You will find many case and series reports but no approved text book will back this as a primary preferred technique for lap surgeries.

So if you get into a medicolegal scenario you might be on a risky wicket.

Having said that there are a lot of things we seem to do in private practice that is equally risky like how many of us use all monitors esp temp, how many of us put all this monitors for a saddle block for a bottom surgery, how many of us actually use the recommended O2 analyser, O2 safety link on our machines and ETCO2 monitors in our private practice in these numerous small hospitals we render anesthesia in.

On a personnel note we attempted SAB for LAP appendicectomy as a study. We started the study 3 different times and all the times gave up this study due to extreme patient discomfort. Incidentally all these studies were attempted when I was teaching at one of the top medical schools in our country.

SO personally I cannot figure out a patient being comfortable unless you have used  plenty of sedation, narcotics and ketamine.
But all these durgs can depress respiration leading to CO2 retention and can also compromise the ability to protect airway.

In lap surgeries we need to increase ventilation to remove the increased absorbed CO2 and we also need to protect airways adequately because the increase in intra-abdominal pressure will increase the risk of regurgitation.
So I think using excess sedation seems to defy the logic of physiological changes that occur during lap surgery

T he one thing that RA may provide of benefit to the patient may be the ability to counter the increase in BP produced by CO2 insuffulation
Recently I saw a study where in Lap surgery SAB was done and CLonidine given at 30 mcg and then GA was given. Produced stable heamodynamics. But I think if clonidine was given IV or orally it would have the same effect. Need to check that out.


My final thoughts
Anaes technique should offer the best safety to the patient both theoretically and to save your skin medico legally
I would base on available scientific evidence strongly recommend GA with ET CO2 monitoring

regs
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neelam nalge

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Re: laproscopic cholecystectomy under spinal anesthesia
« Reply #4 on: May 06, 2010, 11:17:14 PM »
Hello;
     many of my friends are doing lap chols under SA routinely but whenever I have tried it
      I end up having a very uncomfortable and restless pt whom I end up giving too much of additional iv supplement drugs.(cocktails as mixup is referred).Then started with epidurals with GA for sometime.now with clonidene at hand we give 100mi gm tab 2 hrs before the induction and iv fentanyl 1migm per kg during induction.bp remains around 100mm
 systolic till co2 insfn and in good control thruout the surgery.
    sometimes observed severe bradycardia after induction but responds to atropine.
   IN 2 cases had to use iv clonidene upto 75 migms intraop to control the bp.
  I am happy with this,but would like any suggestions for improvement.
     (2)I feel we don't havemuch literature supporting use of regionals in lap surgeries may be because more of the use is very recent,and many times it is done in compromised setups or patients,sonot published. not very sure,
   
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