Interpretation (in light of other evidence)
An adequate and lasting post-operative pain control is crucial to enhance recovery16. Regarding postoperative pain, our result confirms the findings already registered in laparoscopy cholecystectomy under RA: less pain is registered especially in the first postoperative hour 13,17,18 and this can be considered of foremost importance as long as the early onset of pain right after surgery is capable to affect the whole recovery phase16. This result might be explained by the persistent neuraxial blockade. In order to enhance this effect in our study clonidine was administered to the patient who underwent RA. Clonidine is an α2 adrenergic agonist used like an adjuvant in anesthesia. There were different possible mechanisms to explain the enhanced anesthetic efficiency. According to some researchers, the action of α2-agonism of clonidine induces vasoconstriction, which might contribute to prolonging the analgesia time. Furthermore, clonidine potentiates the spinal block via synergistic interaction between α2 receptors and sodium channels, resulting in a reduction in the dose of the local anesthetics required for achieving effective spinal anesthesia for certain surgical procedures 19,20.
Duration of surgery for women who underwent RA was comparable to the control group and the whole surgical team, questioned about pelvic organ exposure at the end of the procedure, gave in agreement positive feedback. This data, in particular, is encouraging given that one of the main concerns regarding the execution of this anesthesia for gynecological laparoscopic procedure is the difficulty to achieve a sufficient degree of Trendelenburg’s position (a key factor in gynecological surgery to retract bowel and provide adequate visualization) providing at the same time adequate ventilation. In our study, the degree of Trendelenburg’s position obtained in RA group was only 16.33 + 2.97. No case of hypercapnia or pulmonary complication was registered.
RA compared with GA showed a quick recovery in the immediate postoperative setting. Enhanced Recovery After Surgery (ERAS) Protocols encourage the early mobilization of the patients 21. Our data, according to the literature, demonstrate a significantly earlier mobilization in RA group compared to patient underwent general anesthesia. This finding together with the faster resumption of bowel movement, equally founded to be statistically significant in the RA group, is of particular interest in childbearing age women for the preventive effect on post-surgical adhesion formation (a proven factor for infertility disorders) 22. GA has long been considered as causing a greater frequency and severity of PONV than regional anesthetic techniques 23. In our study, patients in the RA group showed a lower incidence of PONV and required fewer drugs to avoid it, although these results were no statistically significant. Two previous studies evaluating PONV among gynecological patients treated with laparoscopy surgery with RA and GA showed discordant results. Raimondo et al. reported a higher incidence rate of PONV in women that received GA whereas Zirak et al. revealed this complication to be more frequent in the RA group9, 24. This divergence could be explained by the presence of a confounding factor, the inflation during laparoscopy, which can be considered by itself a cause of PONV 25,26.
Although our study was not focused on cost analysis, based on our results we can globally consider RA a cost saving alternative to GA, in accordance with Turkstani et al. (who instead performed an accurate comparison of anesthesia cost about spinal versus general anesthesia for laparoscopic cholecystectomy) 27, taking in consideration the reduced amount of drugs used for our patients in the postoperative time and the earlier discharge.
Great motivation for the patient is mandatory to accomplish this technique and patient anxiety must be addressed before surgery with appropriate counseling but communication with an empathetic anesthesiologist and surgeon just during surgery may help significantly to reduce patients’ anxiety. In this regard, we considered it essential to inform the patient about each step of the surgery ( showing on request the live procedure on the screen) and obtain his feedback even during surgery.
Considering all the steps, a maximum of 2 points on the Likert scale (considered a mild pain) was recorded: only 3 cases with a score of 3 during skin suture were registered.
Finally, another important advantage of RA, to not be underestimated during the ongoing COVID-19 pandemic, is the avoidance of airway management that can prevent the risk of virus spread28.