The appendectomy is one of the world’s most frequently performed operations [1]. For decades, the dominant technique was the open appendectomy, but laparoscopic appendectomy has taken its place as the method of choice for treating appendicitis patients [1]. Now, at least 38.1% of appendectomies are laparoscopically performed, and research suggests that this rate could be higher if not for resource shortages in less-developed countries [1, 2]. Each technique for appendectomy requires different anesthesia considerations that medical teams should take to ensure that operations are successful.
While laparoscopic appendectomies were traditionally performed under general anesthesia (GA), recent research has indicated the comparative advantages of other anesthesia approaches [1, 3]. Most specifically, spinal/epidural anesthesia (SEA) has been the topic of several significant experiments. In non-appendectomy contexts, SEA has resulted in reduced surgical stress, postoperative pain, and postoperative nausea/vomiting in comparison to GA, in addition to lower requirements for airway management [1].
Based on SEA’s positive record of success, Erdem et al. compared the effects of SEA and GA during laparoscopic appendectomies [1]. Of their 50 patients, they found that the SEA group exhibited a lower incidence of postoperative right shoulder pain, nausea, and vomiting, albeit in insignificant quantities [1]. Nevertheless, the researchers concluded that SEA is a safe and feasible alternative to GA [1]. These findings have since been corroborated by multiple other studies. For instance, Uzman et al. found that spinal/epidural anesthesia produced acceptable postoperative pain control while avoiding intubation-associated complications and significant bouts of postoperative nausea/vomiting [3].
Since the establishment of spinal/epidural anesthesia as a satisfactory alternative to general anesthesia for laparoscopic appendectomy patients, researchers have sought to identify the anesthetics associated with the best outcomes. One study compared lidocaine, ropivacaine, and levobupivacaine [4]. Its authors found that levobupivacaine was associated with the lowest pain intensity, while ropivacaine was next most effective [4]. Jun et al. also found that dexmedetomidine could be a feasible means of administering local anesthesia to laparoscopic appendectomy patients, but it may require supplemental ketamine or fentanyl injection, as well as careful monitoring to avoid bradycardia [5].
For patients undergoing open appendectomy, anesthesia providers have also moved away from general anesthesia [2]. This is due to the adverse events associated with GA, such as intubation- and extubation-related complications and hemodynamic instability [2]. By contrast, neuraxial anesthesia (NA) has contributed to shorter hospital stays and reduced the risk of postoperative complications [2]. Gabriel et al. supported these findings when they found that spinal anesthesia promoted shorter hospital stays, better oral tolerance, and fewer adverse effects [6]. However, there may not be a significant postoperative pain difference between the two techniques [2]. Moreover, the difference between NA and GA may not be as significant when experienced surgeons operate in non-complex contexts [6]. Regardless, in more complicated surgical settings, NA appears advantageous.
When GA is unavoidable due to resource shortages or other limitations, a transversus abdominis plane (TAP) block can reduce patients’ postoperative pain levels [7]. In an experiment comparing TAP block to a control group (one received normal saline; the other, Marcaine), the TAP block group was more satisfied [7]. They required fewer postoperative analgesics and exhibited fewer side effects and complications [7].
Whether a patient is undergoing an open or a laparoscopic appendectomy, spinal anesthesia may promote the best possible outcomes. When spinal anesthesia is a viable option, opting for supplemental methods that reduce the prominent issues associated with general anesthesia is crucial to ensuring patient satisfaction.
References
[1] V. M. Erdem et al., “Spinal/epidural block as an alternative to general anesthesia for laparoscopic appendectomy: a prospective randomized clinical study,” Videosurgery and other Miniinvasive Techniques, vol. 13, no. 2, p. 148-156, January 2018. [Online]. Available: https://doi.org/10.5114/wiitm.2018.72684.
[2] M. E. Moheb et al., “General Versus Neuraxial Anesthesia for Appendectomy: A Multicenter International Study,” World Journal of Surgery, vol. 45, no. 11, p. 3295-3301, November 2021. [Online]. Available: https://doi.org/10.1007/s00268-021-05978-9.
[3] S. Uzman et al., “Combined spinal-epidural anesthesia in laparoscopic appendectomy: a prospective feasibility study,” Annals of Surgical Treatment and Research, vol. 92, no. 4, p. 208-213, March 2017. [Online]. Available: https://doi.org/10.4174/astr.2017.92.4.208.
[4] S. Čustovic, H. Pandža, and S. Delibegovic, “Effect of Local Anesthesia on the Postoperative Pain After Laparoscopic Appendectomy,” Journal of Laparoendoscopic & Advanced Surgical Techniques, vol. 29, no. 1, p. 65-71, January 2019. [Online]. Available: https://doi.org/10.1089/lap.2018.0452.
[5] G. W. Jun et al., “Laparoscopic appendectomy under spinal anesthesia with dexmedetomidine infusion,” Korean Journal of Anesthesiology, vol. 67, no. 4, p. 246-251, October 2014. [Online]. Available: https://doi.org/10.4097/kjae.2014.67.4.246.
[6] M. Gabriel et al., “Comparison Between Spinal Anesthesia Vs General Anesthesia in Patients Undergoing Open Appendectomy for Acute Appendicitis, A Retrospective Study,” Journal of Hepatology and Gastrointestinal Disorders Research, vol. 7, no. 178, p. 1-5, December 2020. [Online]. Available: https://doi.org/10.35248/2475-3181.7.178.
[7]M. K. Shahmoradi, G. Besharatifar, and H. R. Taheri, “Analgesic effects of TAP block among open appendectomy patients and the need of postoperative pethidine for Pain Management: A randomised controlled trial,” International Journal of Surgery Open, vol. 27, p. 166-171, November 2020. [Online]. Available: https://doi.org/10.1016/j.ijso.2020.11.015.