Pneumoperitoneum in laparoscopy under regional anaesthesia: nitrous oxide vs carbon dioxide

S.M. Byshovets

Abstract


Background. Regional methods of anaesthesia in laparoscopy have certain advantages over anaesthesia. Carboxyperitoneum with laparoscopy is common, but when performing surgery under high spinal anaesthesia (Th2–3), the diaphragm remains intact. Phrenic nerve irritation with carbon dioxide causes a severe humeroscapular pain syndrome, which requires the use of general anaesthesia. The aim of the work is to improve anaesthetic management of laparoscopy by combi­ning regional anaesthetic techniques — spinal anaesthesia, right-sided superficial cervical plexus block and terminal anaesthesia of the diaphragm surface using dinitrogenoxideperitoneum instead of carboxyperitoneum. Materials and methods. The study involved 300 patients (age 55.5 ± 3.3 years, body weight 76.8 ± 2.4 kg, body mass index 29.2 ± 0.9 kg/m2, I–III ASA). The spectrum of diseases: cholecystitis, hernia, ovarian cyst, varicocele, uterine fibromyoma, adhesive disease, acute appendicitis, abscess/cyst of the liver. Anaesthetic management: spinal anaesthesia with hyperbaric bupivacaine (10–20 mg) in combination with 0.06 mg buprenorphine; to prevent hume­roscapular pain syndrome — right-sided cervical plexus superficial block by bupivacaine (0.125%, 10 ml), spraying of the diaphragm with lidocaine (3%, 10 ml, through the laparoscopic port), to create pneumoperitoneum — nitrous oxide. Before the surgery, patients received: orally — 6 mg melatonin at bedtime the day before intervention, and 1 h before laparoscopy; orally/intravenously — 1 g paracetamol; intramuscularly — 20 mg nefopam; intravenously — 8 mg dexamethasone, 8 mg ondansetron, 50 mg dexketoprofen. After surgery, for one/two days: orally — 1 g paracetamol every 8 h, intravenously — 50 mg dexketoprofen every 8 h. Results. After premedication, the patients were in a calm psycho-emotional state. Muscular tremors were not observed in the perioperative period. The adequacy of anaesthesia was determined by patients who characterized their condition as “complete absence of pain”. There were no complaints of pain in the shoulder and scapula. In 100 % of cases, sedation of varying degrees developed. The mechanism of this phenomenon is probably associated with the resorption of intrathecal buprenorphine and intra-abdominal nitrous oxide. With spontaneous breathing, there was no respiratory dysfunction. Stabilization of hemodynamics was carried out by adrenaline tartrate (0.019–0.038–0.057 μg/kg/min). After surgery, the patients were immediately transferred to profile departments. On average, patients were activated 2–3 h after transfer from the operating room. In the first postoperative day, enteric feeding was started. The quality of the postoperative analgesic profile was characterized positively. There was no need for additional prescription of opioids. The severity of pain syndrome was assessed by a numerical rating scale of pain from 0 to 10 points 3, 10, 24 and 48 h after the operation. The dynamics was as follows (M ± m): 0; 0.27 ± 0.02 (p = 0.157); 0.41 ± 0.07 (p = 0.0001); 0.45 ± 0.06 (p = 0.0001). The period of hospitalization was 31.0 ± 1.6 h. Conclusions. Carbon dioxide is more toxic when creating pneumoperitoneum for laparoscopy in comparison with nitrous oxide. Dinitrogenoxideperitoneum together with superficial cervical plexus block and terminal anaesthesia of the diaphragm prevented the onset of humeroscapular pain syndrome. Replacement of carboxyperitoneum with dinitrogenoxideperitoneum made it possible to perform laparoscopic surgeries under simultaneous regional anaesthesia, avoiding general anaesthesia with known side effects.


Keywords


pneumoperitoneum; laparoscopy; regional anaesthesia; nitrous oxide; carbon dioxide

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DOI: https://doi.org/10.22141/2224-0586.2.89.2018.126609

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