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.