Spinals versus GA for cholecystectomy

[cfdavid]

So, I just spent a week with general surgical residents. It was a great experience.

I've seen a handful of laproscopic cholecystectomies and most were under GA. But, this one dude had conscious sedation with an L4/L5 spinal.
I didn't get a chance to ask the anesthesiologist doing the procedure about the indications.

What is the correct name for this L4/L5 "spinal" procedure in which he was clearly in the lumbar cistern (he showed my how he was making sure he was into CSF etc.)?? Also, what are the indications for this versus GA?? I know this is very basic, but other students may benefit as well.

Thanks,

cf

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[jwk]

So, I just spent a week with general surgical residents. It was a great experience.

I've seen a handful of laproscopic cholecystectomies and most were under GA. But, this one dude had conscious sedation with an L4/L5 spinal.
I didn't get a chance to ask the anesthesiologist doing the procedure about the indications.

What is the correct name for this L4/L5 "spinal" procedure in which he was clearly in the lumbar cistern (he showed my how he was making sure he was into CSF etc.)?? Also, what are the indications for this versus GA?? I know this is very basic, but other students may benefit as well.

Thanks,

cf

I don't think there are any indications for doing a lap chole under SAB - and I have a hard time believing it would be done that way.

 

[jetproppilot]

So, I just spent a week with general surgical residents. It was a great experience.

I've seen a handful of laproscopic cholecystectomies and most were under GA. But, this one dude had conscious sedation with an L4/L5 spinal.
I didn't get a chance to ask the anesthesiologist doing the procedure about the indications.

What is the correct name for this L4/L5 "spinal" procedure in which he was clearly in the lumbar cistern (he showed my how he was making sure he was into CSF etc.)?? Also, what are the indications for this versus GA?? I know this is very basic, but other students may benefit as well.

Thanks,

cf

Nice question, CF.

Lemme let you in on a little secret of our profession.

We always document which level we've accessed the spinal/epidural space.

Problem is, we're guessing, since we aint got no fluoroscopy to count the levels.

Its a guess.

An educated one, yes.

But still a guess.

SO, the correct name for the L4L5 spinal procedure would be documented as follows:

"SAB via sterile technique..L4L5....25 gauge spinal needle....(+) CSF, (-) heme, (-) paresthesias....bupivicaine hyperbaric 15mg slow.....spinal needle removed....to supine....

Can't think of why someone would go as low as L4L5, but hey, theres many ways to do this biz....

More importantly, doing a lap-chole under spinal is, uhhhh, unconventional.

Can't say I've ever done that in eleven years of private practice.

But I'm all ears......

 

[BlackSails]

More importantly, doing a lap-chole under spinal is, uhhhh, unconventional.

Can't say I've ever done that in eleven years of private practice.

But I'm all ears......

Whenever someone is poking around my insides, I want GA.

 

[cfdavid]

Sh..t, guys I'm SO sorry about this. This past week's been very busy, and I've seen a lot that I've never seen before.... I was also kind of distracted when I posted earlier. Honestly, I got the cases mixed up and I guess I didn't think before hitting the "enter" button......

I feel so bad about this, but the procedure was a hernia repair (open)and not a lap chole.....lol Oh ****. I guess there's a little bit of a difference between the two.... Come on, pile on. I deserve it.

Nevertheless, I guess this explains the responses.

BUT, are such repairs always done via a spinal?? The other open repair I saw, I kind of just walked in on. I didn't actually see the anesthesia being administered at the begining. What are the specific advantages of a block versus GA?

 

[2ndyear]

Simple inguinal hernia repairs can usually be done with a local block by the surgeon and sedation, if you have a cooperative patient. Spinals are relatively uncommon for this where I am. That doesn't make it wrong. Problems with spinals are that it's usually a one shot technique so we have to pick the right local anesthetic and hope that the surgeons can either finish before the block wears off, or not overshoot so much that the patient is in the PACU for 4 hours waiting for their legs to come back.

 

[bullard]

Simple inguinal hernia repairs can usually be done with a local block by the surgeon and sedation, if you have a cooperative patient. Spinals are relatively uncommon for this where I am. That doesn't make it wrong. Problems with spinals are that it's usually a one shot technique so we have to pick the right local anesthetic and hope that the surgeons can either finish before the block wears off, or not overshoot so much that the patient is in the PACU for 4 hours waiting for their legs to come back.

Hahah....the other day I had two inguinal hernias booked as MAC that I had to convert to GA b/c surgeon probably didn't use enough local. The first one really sucked b/c my attending was like, "why throw in an LMA? You're not gonna do peds for another year (I'm just one month into my training)...let's mask him for the rest of the case." 45 minutes later, I wanted to smack her but my hand hurt too much.

We have another surgeon who always does these laparoscopically (just one side, not bilateral hernias where I guess lap is indicated) with some fancy robot thing...usually takes at least 2 hours.

 

[jwk]

Hahah....the other day I had two inguinal hernias booked as MAC that I had to convert to GA b/c surgeon probably didn't use enough local. The first one really sucked b/c my attending was like, "why throw in an LMA? You're not gonna do peds for another year (I'm just one month into my training)...let's mask him for the rest of the case." 45 minutes later, I wanted to smack her but my hand hurt too much.

We have another surgeon who always does these laparoscopically (just one side, not bilateral hernias where I guess lap is indicated) with some fancy robot thing...usually takes at least 2 hours.

The joys of academia.

Although open inguinal hernias can be done with a block and sedation, general is still the easiest way to go. SAB and epidural are options as well, and I would opt for either one of these before a block.

I can't tell you why some hernias are done laparoscopically and some open. Bilateral laparascopic repairs are not uncommon. We haven't done any robotic repairs yet and I hope we don't. I'm convinced on robotic prostatectomies, but I haven't seen any other GU or GYN procedures so far where I can tell there are any advantages to it, and the costs are dramatically higher, both from an equipment as well as billable time standpoint.

Can laparoscopic cases be done under spinal or epidural? Yes - I've done exactly one, a laparasopic tubal ligation. It was a pain, and I would never do another one that way. The incisional pain is not a problem. Abdominal insufflation is. Toss in a steep trendelenberg position for a GYN case, and it just ain't worth the hassle.