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6 Sunamak et al., Combined Spinal/Epidural Anesthesia / doi: 10.14744/hnhj.2017.60783 Although general anesthesia (GA) has been traditionally used in LC, the use of spinal (SA), epidural (EA), and combined spinal epidural anesthesia (CSEA) has increased in recent years [6,7,8]. Regional anesthesia has advantages, such as smaller surgical incision, lesser shoulder pain, lesser nausea and vomiting, and lower neuroendocrine response in the postoperative period than those in GA [6,9]. Rodgers et al. [10] reported in their meta-analysis that the application of neuraxial techniques resulted in a reduced mortality rate. In addition, the number of patients with venous thromboembolism and myocardial infarction has decreased when using neuraxial techniques. Despite these advantages, an anesthesiologist must overcome problems pertaining to pneumoperitoneum and spinal anesthesia-related perand postoperative complications and provision of sufficient neural block for surgical procedures [6,7,8,9]. There are few studies on LC under CSEA; CSEA in LC has not been analyzed as much as SA aor EA [9,12,13]. We analyzed perand postoperative side effects and patient satisfaction in 112 patients who underwent LC under CSEA. Materials and Methods This retrospective study was conducted in general surgery clinics. Ethics committee approval was obtained, and the study was conducted in accordance with the Declaration of Helsinki. We obtained written informed consent from the patients. Data from 112 patients who underwent elective LC under CSEA for gall stones or polyps were retrospectively analyzed. Patients with contraindications for SA or pneumoperitoneum, spinal deformity, cooperation difficulty, or psychiatric illness; those younger than 18 years of age; and those who were pregnant did not undergo surgery with CSEA. The anesthesia procedure and LC were performed by the same anesthesiologist and surgeon, respectively, for all the patients. All patients were preoperatively informed about the side effects, such as shoulder pain, abdominal discomfort, and anxiety, which might develop during the procedure, and that they could be treated by additional intravenous medication. If this did not result in adequate pain relief, conversion to GA was considered an option. Preoperative medication was not administered to any of the patients. To prevent hypotension, 10 ml/kg Ringer’s lactate was intravenously administered 20 min before the start of the CSEA procedure. A standardized CSEA technique was used in all patients, which included the following: a) patient in a sitting position; b) use of needle-through-needle CSEA technique with an 18-G Tuohy needle at the L3–L4 interspace, loss-of-resistance to saline technique, and 26-G pencil point spinal needle (Perifix®, Braun, USA); c) subarachnoid injection of 15 mg hyperbaric bupivacaine for over 30 s to which 10 μg of fentanyl was added via the long spinal needle; and d) insertion of the epidural catheter to a depth of 3–4 cm in cranial direction. EA was performed by administering 20 ml of a mixture of 10 ml bupivacaine (0.5%; 50 mg), 5 ml lidocaine (2%), 1 ml fentanyl, and 4 ml isotonic saline solutions through the epidural catheter into the epidural space. The patients were positioned in the 15° Trendelenburg position. The repeated pin-prick test at 1-min intervals was used to check the sensorial block level, and when the block reached the T4 dermatome level, the surgery was initiated. An insufficient level of anesthesia, failure to cope with intraoperative complaints, or patient’s choice was the criteria for conversion to GA. Low-pressure (10 mm Hg) CO2 pneumoperitoneum was used, and a standard four-trocar LC was performed. Electrocardiography (ECG), noninvasive arterial blood pressure (NIBP), heart rate (HR), respiratory rate (RR), and peripheral oxygen saturation (SpO2) were continuously monitored for all patients. Patient demographics, ASA scores, comorbidities, surgery time (the time between skin incision and end of skin closure), anesthesia time (the time between spinal entry and achieving anesthesia level), and total time (the time between spinal needle entry and end of skin closure) were recorded. Additionally, pneumoperitoneum or CSEA-related peroperative complications, such as hypotension (decrease in mean arterial pressure by ≥30% or decrease in systolic arterial pressure to <90 mm Hg), bradycardia (HR <50 bpm), hypoxemia (SpO2 <90%), nausea/vomiting, right shoulder pain, anxiety, or abdominal discomfort and/ or pain were recorded. Shoulder pain, PDPH, nausea/vomiting, urinary retention, anxiety, and abdominal discomfort and/or pain were recorded during the postoperative period. Intravenous fluid replacement with 1 L of Ringer’s lactate and 1 L of isotonic saline was performed during the first 24 h following surgery. On postoperative days 3 and 7, the patients were evaluated for surgical complications (choledochal injury, hemorrhage, and vascular injury). A visual analog scale (VAS) was used to evaluate postoperative pain (0, no pain to 10, severe pain), and data were recorded at 2, 4, 6, 12, and 24 h. Additionally, a five-parameter Likert scale was used to evaluate patient satisfaction before discharge (1, dissatisfied to 5, very satisfied). The Statistical Package for Social Sciences, version 16.0 (SPSS Inc., Chicago, Illinois, USA) was used for statistical analysis of study results. Data are presented as the mean±SD or number and percentage of patients. 7 Sunamak et al., Combined Spinal/Epidural Anesthesia / doi: 10.14744/hnhj.2017.60783

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Laparoscopic Cholecystectomy under Combined Spinal/Epidural Anesthesia: A Retrospective Analysis of 112 Cases in Terms of Per and Post operative Outcomes