Procedures
In the operating room, venous access was placed (18 G) and antibiotic
prophylaxis was administered (Cefazolin 1 or 2 gr. iv, or in case of
allergy, Clindamycin 600 mg iv) 30 min before skin incision, also
dexamethasone 4 mg iv and midazolam 1 mg iv w administered. Vital signs
were monitored: SpO2, heart rate and blood pressure
every 5 minutes.
In the sitting position,in group A , RA was performed at the T9-T10 or
T10-T11 level. The level of puncture was confirmed by ultrasound
counting the vertebrae from the sacrum, in a caudo-cranial sense. The
technique was performed in asepsis. In the subarachnoid space after the
vision of clear cerebrospinal fluid (CSF) in the spinal needle 27 Gauge,
without letting out the CSF, Ropivacaine 0.375% 18 mg, Sufentanyl 7
mcg, and Clonidine 20 mcg were injected. Intraoperative sedation was
carried out with midazolam 0.05 mg/kg and fentanyl 1 mcg/ kg when
pneumoperitoneum was performed. The anesthetic plane, suitable to the
surgical procedure (T1-S4), was tested with the Pinprick and Ice test.
Group B patients undergoing GA received propofol (2 mg/kg), sufentanil
(0.5 mcg/kg) and rocuronium bromide (0.6 mg/kg) for the induction of the
anesthetic plane. The maintenance of the anesthetic plane was ensured
with sevoflurane from 1% to 2%. Residual neuromuscular block
antagonized with sugammadex 2-4 mg/kg about TOF.
The management of postoperative pain was based on the administration of
Paracetamol 1000 mg in the case of VAS < 5 and the
administration of Ketorolac 30 mg in the case of VAS ≥ 5.
In case of inadequate analgesia, after 60 minutes of the Ketorolac after
administration, Tramadol 100 mg i.v. was administered, these patients
were no longer valuable and reliable for our study.
The incidence of PONV was considered and ondansetron 4 mg i.v. was
administered in case of manifestation of the complication. If after 60
minutes PONV still occurred, dexamethasone 4 mg i.v. was administered.
Pneumoperitoneum induction was achieved by open laparoscopy (Hasson
technique) in order to avoid the high intraperitoneal pressure,
otherwise necessary for the blind insertion of the first trocar, when
performing the closed technique (Veress technique). Thus, the procedure
was started with a low pressure of 8mmHg and slowly increased to high
flow, and pressure not higher than 11 mmHg was maintained throughout the
entire surgery. Patients were placed into a minimal Trendelenburg
position (maximum 20°) able to provide adequate visualization and bowel
retraction. Ultrasound energy to cut and coagulate instead of
monopolar/bipolar energy was used to perform salpingectomy or
adnexectomy allowing to save time and reduce tissue trauma.