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99]

Review Article

Anaesthesia for laparoscopic surgery:

General vs regional anaesthesia
Sukhminder Jit Singh Bajwa, Ashish Kulshrestha
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Patiala, Punjab, India

Address for Correspondence: Dr. Sukhminder Jit Singh Bajwa, House No - 27-A, Ratan Nagar, Tripuri, Patiala - 147 001, Punjab, India.
E-mail: sukhminder_bajwa2001@yahoo.com

Abstract INTRODUCTION

The use of laparoscopy has revolutionised the surgical
field with its advantages of reduced morbidity with early
recovery. Laparoscopic procedures have been traditionally
performed under general anaesthesia (GA) due to the
respiratory changes caused by pneumoperitoneum, which
is an integral part of laparoscopy. The precise control of
ventilation under controlled conditions in GA has proven
it to be ideal for such procedures. However, recently
the use of regional anaesthesia (RA) has emerged as
an alternative choice for laparoscopy. Various reports
in the literature suggest the safety of the use of spinal,
epidural and combined spinal-epidural anaesthesia in
laparoscopic procedures. The advantages of RA can
include: Prevention of airway manipulation, an awake
and spontaneously breathing patient intraoperatively,
minimal nausea and vomiting, effective post-operative
analgesia, and early ambulation and recovery. However,
RA may be associated with a few side effects such as
the requirement of a higher sensory level, more severe
hypotension, shoulder discomfort due to diaphragmatic
irritation, and respiratory embarrassment caused by
pneumoperitoneum. Further studies may be required to
establish the advantage of RA over GA for its eventual
global use in different patient populations.
Key words: General anaesthesia (GA), laparoscopy,
pneumoperitoneum, spinal anaesthesia
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The introduction of laparoscopy in the field of surgery in the
mid-1950s revolutionised surgical techniques due to reduction
in overall medical costs, reduced bleeding, less post-operative
surgical and pulmonary complications, and early recovery.
The gradual shift of laparoscopy to include more complicated
surgical procedures resulted in modifications of existing
anaesthetic techniques. The various effects of induction of
pneumoperitoneum, an integral part of laparoscopy, can result
in respiratory embarrassment and cardiovascular changes best
managed by the use of general anaesthesia (GA).[1] Since the
initiation of the application of laparoscopy in various day-care
surgeries, a more favourable anaesthetic technique is required
allowing early recovery and ambulation. The evolution of
anaesthetic medicine on scientifically and clinically relevant
scales has propelled innovations and initiatives for newer yet
safer techniques.[2] Advancements in anaesthesiology have
been made on many fronts besides clinically relevant scales.[3-5]
On the contrary, advancements in anaesthetic techniques
and drugs in the modern era have given birth and growth to
newer controversies in the light of newer scientific evidences.
Traditionally, GA was considered the sole technique, and
various myths and facts discouraged the use of regional
anaesthesia (RA). Among these, respiratory embarrassment
and cardiovascular changes were the major aspects of concern
which are considered to be best managed by the use of GA.
Moreover, anaesthesiologists are more comfortable with the
administration of GA in laparoscopic surgeries, and there is
a general reluctance to take initiative for advancements in
swapping anaesthetic techniques.

Recently, RA has been documented to be equally favourable

DOI:
10.4103/0972-9941.169952 in laparoscopic surgeries.[6] This review has been done to
compare the merits and demerits of the use of RA vs GA in
laparoscopic surgery.

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Bajwa and Kulshrestha: GA vs RA for laparoscopic surgery
METHODS OF LITERATURE SEARCH
A systematic literature search was made using search engines
including PubMed, Google and Google Scholar with the
use of the following single-text words and combinations:
‘Laparoscopic surgery’, ‘regional anaesthesia’, ‘general
anaesthesia’ and ‘spinal anaesthesia’. The references of
relevant articles were cross-checked, and the articles
comparing RA with GA for laparoscopic surgery and the
articles on the use of RA for laparoscopic surgeries were
included.
SYSTEMIC EFFECTS OF PNEUMOPERITONEUM–
NECESSARY CLINICAL SCENARIO
The creation of pneumoperitoneum is an integral part
of any laparoscopic procedure and is usually done by
insufflation of carbon dioxide for the proper visualisation
of abdominal viscera and its manipulation. The main
effects are due to raised intra-abdominal pressure leading
to various respiratory, cardiovascular and neurologic
alterations.
Cardiovascular
The cardiovascular effects are mainly dependent on the
intra-abdominal pressure and the absorption of carbon
dioxide into systemic circulation. At lower intra-abdominal
pressures of less than 15 mmHg, the venous return is
augmented due to the emptying of splanchnic vessels, and
thus cardiac output and blood pressure are increased. At
higher intra-abdominal pressures of more than 15 mmHg, due
to compression of inferior vena cava and other collaterals,
the venous return is decreased, thus reducing cardiac output
and blood pressure.[7,8] Various bradyarrythmias leading
to atrioventricular blocks and cardiac arrest have been
documented due to vagal stimulation on the insertion of a
trocar, peritoneal stretch or carbon dioxide embolization.[9]
Respiratory
These include reduced lung volumes, basal atelectasis,
increased intrapulmonary shunting, raised peak and
mean airway pressures, and are attributable to raised
intra-abdominal pressures and cephalad migration of the
diaphragm with reduced excursion. There may also be
chances of endobronchial migration of the endotracheal
tube, resulting in hypercarbia and hypoxia.[10]
Neurologic
Raised intracranial pressure with consequent reduced
cerebral perfusion pressure may occur due to hypercapnia,
raised intra-abdominal pressures, and head-down positioning.
Journal of Minimal Access Surgery | January-March 2016 | Volume 12 | Issue 1
These changes can be detrimental in patients with reduced
intracranial compliance.
Positioning
The most common laparoscopic procedures employ the
Trendelenburg (head-up) or the reverse Trendelenburg
(head-down) position, thus further potentiating the adverse
effects of pneumoperitoneum. The venous return, cardiac
output and mean arterial pressure are reduced further in the
head-up position, with an increase in peripheral vascular and
pulmonary resistance.[11] Respiratory system deterioration
is considered to be maximally affected in the reverse
Trendelenburg position but it also depends on the duration
of pneumoperitoneum.[12]
CHOICE OF ANAESTHETIC TECHNIQUE
FOR LAPAROSCOPY– THE BEST ONE
With the recent trend towards the use of laparoscopy in day-
care surgeries, anaesthetic techniques have changed, with
more emphasis on shorter and more favourable techniques.
The ideal anaesthetic technique for laparoscopic surgery
should maintain stable cardiovascular and respiratory
functions, provide rapid post-operative recovery, lead to
minimal post-operative nausea and vomiting (PONV) and
provide good post-operative pain relief for early mobility.
THE TRADITIONAL ANAESTHETIC TECHNIQUE — GA
The use of GA with controlled ventilation has been considered
the most acceptable technique for laparoscopic procedures
owing to the various effects of pneumoperitoneum. The use
of rapidly-acting and shorter-duration intravenous agents
such as propofol and etomidate as well as inhalational agents
such as sevoflurane and desflurane has made GA a favourable
technique for day-care laparoscopic procedures.[13,14] Use of
the ultra-short-acting opioid analgesic remifentanil also
favours GA in fast-track laparoscopic procedures.[15] The
use of nitrous oxide in laparoscopic procedures has been
controversial, but the recent literature does not convey
any clinical advantage of avoiding it against a greater
risk of intraoperative awareness.[16] The only advantage
of avoiding nitrous oxide may be a lower incidence of
PONV. The use of short-acting, non-depolarizing muscle
relaxants has replaced depolarizing muscle relaxants such
as succinylcholine from the balanced GA technique for
laparoscopic surgeries, allowing for less post-operative
muscle pain. Moreover, the increasing usage of newer drugs
like alpha-2 agonists apart from traditionally used opioids
is quite effective in the attenuation of stressor response
during intubation.[17,18]
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Bajwa and Kulshrestha: GA vs RA for laparoscopic surgery
The use of Proseal laryngeal mask airway (LMA) with
controlled ventilation can avoid endotracheal intubation
in selected non-obese patients undergoing laparoscopic
procedures, thus reducing the incidence of post-operative
sore throat, but it should be limited to procedures with the
use of low intra-abdominal pressures and mild tilt.[19,20]
The safest technique of anaesthesia remains GA with
endotracheal intubation in those with no contraindications,
with maintenance of intra-operative end-tidal carbon
dioxide (EtCO2) around 35 mmHg with adjustments in tidal
volume or respiratory rate.[21] The agents which directly
depress the heart should be avoided, with the provision of
anticholinergic drugs in case of sudden surge in vagal tone
during laparoscopy.
EMERGENCE OF RA IN LAPAROSCOPIC SURGERY
The use of RA for laparoscopy had not gained popularity
until recently due to the risk of aspiration and respiratory
embarrassment caused by pneumoperitoneum, making it less
favourable for a conscious patient. However, RA does provide
numerous advantages over GA in terms of quicker recovery,
effective post-operative pain relief, no airway manipulation,
shorter post-operative stay, cost-effectiveness and reduced
PONV.[22,23] Most of the uses of RA in the past have been limited
to the patient population with significant co-morbidities,
where it proved to be beneficial.[24,25] There is evidence that
the use of RA in laparoscopy performed on awake patients
may produce fewer changes in respiratory mechanics and
arterial blood gases. The various regional techniques that
can be safely used in laparoscopic procedures are as follows.
Epidural anaesthesia
It has emerged as a very safe technique for lower abdominal
surgeries as well as for post-operative analgesia, with only
occasional complications reported.[26] It has been used safely
in laparoscopic procedures involving the upper abdomen, and
has been shown to have no deleterious effects on respiratory
mechanics. The effectiveness of the epidural technique is
enhanced and a prolonged post-operative analgesic period is
achieved with the use of adjuvant with local anaesthetics.[27-29]
Epidural anaesthesia can be used in patients deemed unfit for
GA with the provision of effective post-operative analgesia.[30]
Spinal anaesthesia
The spinal anaesthesia may be more feasible and can provide
better laparoscopic surgical conditions due to profound
muscle relaxation and shorter recovery. There has been
several reports in the literature for the safe use of spinal
anaesthesia for laparoscopic upper abdominal and lower
6 Journal of Minimal Access Surgery | January-March 2016 | Volume 12 | Issue 1
abdominal procedures.[31-33] The main advantages of spinal
anaesthesia are: An awake, spontaneously breathing patient;
prevention of airway manipulation; less incidence of PONV;
and the provision of effective post-operative analgesia with
a shorter recovery time.[34]
There are a few concerns related to the use of spinal
anaesthesia for laparoscopic procedures. The incidence of
hypotension has been noted to be up to 20.5% and can be
augmented by the Trendelenburg position and increased
intra-abdominal pressures.[35] However, various studies show
that it can be easily prevented by liberally preloading the
patient, reducing the head tilt, reducing the intra-abdominal
pressure and the liberal use of vasopressors.[36,37]
The incidence of referred shoulder-tip pain varies 25-43%; it may
be distressing to the patient in the post-operative period.[38]
The etiology is thought to be subdiaphragmatic irritation of the
peritoneum by the carbon dioxide pneumoperitoneum. This
can be reduced by lowering of the intra-abdominal pressures
to 8-10 mmHg, the instillation of local anaesthetics into the
peritoneal cavity or the use of parenteral opioids.[39,40]
T h e c h a n g e s i n re s p i r a t o r y m e c h a n i c s d u e t o
pneumoperitoneum may cause increase in PaCO 2 due
to absorption from peritoneum, resulting in ventilatory
changes. However, various reports in the literature support
non-significant changes in either PaO2 or PaCO2 during
laparoscopic surgery under spinal anaesthesia.[41]
Combined spinal-epidural anaesthesia
The use of combined spinal-epidural anaesthesia offers many
advantages over either of the techniques by ensuring rapid
onset of anaesthesia compared to epidural alone and reduced
intrathecal doses of local anaesthetics required compared to
spinal anaesthesia. It also entails the provision of effective
post-operative analgesia and early ambulation of patients.
The incidence of side effects is low with slight alterations
in the positioning of the patient and by restriction of intra-
abdominal pressures.[42]
GA VS RA — CURRENT EVIDENCE
Evidence is lacking from developing nations regarding
various advancements, mainly owing to the practice of
scarce reporting of advancements and innovations. However,
recently data reporting has witnessed a slight uptrend in
the developing nations imbibing empiricism and scientific
evidence.[43,44] RA provides various advantages over GA,
such as reduction of surgical stress response, prevention of
airway instrumentation, provision of effective post-operative
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Bajwa and Kulshrestha: GA vs RA for laparoscopic surgery

analgesia, and early ambulation with lower incidence of
deep vein thrombosis. There are numerous studies in the
literature comparing GA and RA for laparoscopic surgery,
which suggests that RA may be a good alternative. The
main concerns associated with the use of RA are accelerated
hypotension due to sympathetic blockade, ventilatory
changes due to the higher sensory levels required, occurrence
of shoulder-tip pain due to diaphragmatic irritation, and
increased surgical time due to limitation of the intra-
abdominal pressure.
Turkstani et al. compared GA with spinal anaesthesia in
50 patients undergoing laparoscopic cholecystectomy (LC)
and found significantly lower pain scores with lower analgesic
consumption in the post-operative period in those with
spinal anaesthesia. The total length of hospital stay was not
significantly different but the total cost of anaesthesia was
significantly less in the spinal anaesthesia group. Shoulder-tip
pain was recorded in 48% of patients and the hypotension
was also seen in 8 patients, but both of these complications
were easily controlled.[45]
Imbelloni et al. in their comparison of 68 patients undergoing
LC under general or spinal anaesthesia also found spinal
anaesthesia to be a safe and cost-effective technique,
with 47% incidence of shoulder-tip pain and 41% incidence

Table 1: Showing studies comparing GA vs RA in laparoscopic cholecystectomy

Authors Number of patients
included
Imbelloni et al. 33 patients in GA (n=33) vs 35
Patients (n=35) in spinal
group using low pressure
pneumoperitoneum (8 mmHg)
Ellakany 20 patients each in GA vs spinal
group (n=20) using low pressure
pneumoperitoneum (10 mmHg)
Mehta et al. 30 patients each in spinal vs GA
(n=30) using normal pressure
pneumoperitoneum (12 mmHg)
Tiwari et al. 114 patients in GA (n=114)
vs 110 patients in spinal
group (n=110) using low
pressure (8-10 mmHg)
pneumoperitoneum
Turkstani et al. 25 patients each in GA vs spinal
group (n=25) using low pressure
(≤10 mmHg) pneumoperitoneum
GA: General anaesthesia, RA: Regional anaesthesia, PACU: Post-anaesthesia care unit, VAS: Visual analogue scale
Outcomes measured Results
Post-operative pain, Significantly lower pain at 2 h, 4 h and 6 h post-
hemodynamic parameters, operatively in spinal group with lower cost and
complications, recovery, patient complete satisfaction. Perioperative vasopressor
satisfaction and cost was given in 41% of patients in spinal group vs 3%
of patients in GA group. 47% of patients in spinal
group had shoulder-tip pain requiring analgesics
Post-operative pain, intraoperative Significantly lower recovery and discharge time
parameters, complications, (81 min vs 111.9 min) with good patient satisfaction
recovery time and patient scores (3.6 vs 2.9) in spinal group but higher
satisfaction incidence of hypotension and bradycardia (40%)
and abdominal discomfort (25%). The surgeon
satisfaction scores were higher for GA group
compared to regional group (3 vs 4.1)
Post-operative pain, intraoperative Significantly reduced pain scores (VAS) at 4 h, 8 h,
and post-operative complications, 12 h, 24 h post-operatively in spinal anaesthesia
recovery, hospital stay and group with no difference regarding complications,
degree of satisfaction recovery, stay or degree of satisfaction between
two groups. Hypotension was noted in 30%
cases of spinal vs 10% cases in GA group, with
more incidence of shoulder discomfort (10%)
intraoperatively
Mean anaesthesia time, 4 patients from spinal group were converted
pneumoperitoneum time, surgery to GA due to intraoperative events (abdominal
time as primary outcomes pain, anxiety and nausea). Significantly more
and intraoperative events and mean anaesthesia time in GA group but a longer
post-operative pain scores as pneumoperitoneum and total surgery time in spinal
secondary outcomes group (36.11±4.98 vs 34.22±5.83) Significantly
lower pain scores post-operatively in spinal group
at 6 h and 12 h but not at 24 h. The patients in
spinal group had more incidences of hypotension,
urinary retention and pain in back and patients in
GA group had more incidences of abdominal pain,
PONV and sore throat, post-operatively
Post-operative pain scores (VAS), Significantly lower pain scores (VAS) at admission
total dose of analgesic used, to PACU (1.4±0.8 vs 4.7±1.4) with lower analgesic
hospital length of stay and cost of requirements (12% vs 52%) in spinal group
each anaesthetic technique with significantly lower cost of anaesthesia. No
significant difference regarding hospital length
of stay. Intraoperatively, additional analgesics
required in 88% patients in GA vs 12% patients
in spinal group with 48% patients experiencing
shoulder-tip pain in spinal group

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Bajwa and Kulshrestha: GA vs RA for laparoscopic surgery
of significant hypotension, both of which responded to
pharmacological treatment with opioids and vasopressors,
respectively.[46]
Ellakany, in his study of 40 patients receiving either general
or segmental thoracic spinal anaesthesia, found comparable
surgical conditions with superior post-operative analgesia
and significantly better satisfaction scores among patients in
the spinal anaesthesia group. He also found a 40% incidence
of significant hypotension and about 25% incidence of
abdominal discomfort, which were easily managed. He
found no patients with nausea and vomiting in the spinal
anaesthesia group.[47] However, the use of newer, long-acting
anti-emetics like palonosetron reduces the incidence of PONV
to a significant extent.[48]
Mehta et al., in their study of 60 patients, also found
better post-operative analgesia with spinal anaesthesia in
comparison to GA for LC. They found no significant difference
between the groups regarding intraoperative complications,
recovery, length of hospital stay and degree of satisfaction.
There was no incidence of nausea and vomiting in the patients
who received spinal anaesthesia.[49]
All the studies in the literature suggest that RA may be
considered comparable to GA in laparoscopic procedures
regarding surgical conditions, intra- and post-operative
complications, and hospital length of stay, but may be
superior to GA with respect to the PONV, post-operative
analgesia and early recovery.
The salient features of various studies comparing GA with
RA are shown in Table 1.
CONCLUSION
Laparoscopic procedures have been traditionally performed
under GA due to the concerns about pneumoperitoneum-
related respiratory changes associated with it. However,
recently the use of RA has been introduced for these
laparoscopic procedures. The evidence suggests the safety
of the use of spinal, epidural and combined spinal-epidural
anaesthesia in laparoscopy with minimal side effects which
can easily be managed with the available pharmacological
drugs. RA may provide certain advantages over GA, such as
lack of airway manipulation, maintenance of spontaneous
respiration, effective post-operative analgesia, minimal
nausea and vomiting, and early recovery and ambulation.
However, the safety of RA in laparoscopic procedures among
various types of patient populations still needs to be verified
by further studies. Additionally, the technique of anaesthesia
8 Journal of Minimal Access Surgery | January-March 2016 | Volume 12 | Issue 1
for laparoscopic procedures remains a debatable issue
and most of the time it depends upon the experience and
competency of the anaesthesiologist.
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Cite this article as: Bajwa SJ, Kulshrestha A. Anaesthesia for laparoscopic
surgery: General vs regional anaesthesia. J Min Access Surg 2016;12:4-9.
Date of submission: 01-02-2015, Date of acceptance: 12-05-2015
Source of Support: Nil, Conflicts of Interest: None declared.
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