Commentary on “Spinal Versus General Anesthesia for Day-Case Laparoscopic Cholecystectomy: A Prospective Randomized Study”

Bessa et al. ¹ are to be congratulated for performing this prospective randomized clinical study comparing outcomes in patients who had a laparoscopic cholecystectomy performed with either general anesthesia (the standard of care) or spinal anesthesia. They conclude that it is feasible and safe to perform the procedure under spinal anesthesia. The data also demonstrated that fewer patients experienced nausea, vomiting, and pain with spinal anesthesia.

This small study allows for statistical comparison but is underpowered to evaluate the true safety of spinal anesthesia. There is limited information about the criteria for patient selection and enrollment into the study. One inclusion criterion was described as the “absence of co-morbidities requiring extra monitoring during the postoperative period.” It is not clear what this means in relation to coronary artery disease, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, asthma, etc. Information about the American Society of Anesthesiologists classification of patient risk would have been appropriate.

There were 4 patients who needed to be converted from spinal anesthesia to general anesthesia for shoulder pain. The authors do not comment whether any of these patients also had hypotension related to the spinal anesthesia, which occurred in 32% of the group.

The spinal anesthesia group also had less pain when compared with the general anesthesia group. This was due to the effect of the spinal anesthetic during the times of evaluation, which were every 2 hours during the first 8 hours after completion of the cholecystectomy. However, it is interesting that the median visual analog scores for pain in the spinal anesthesia group at 2 and 4 hours were 3 and 4, respectively. There is no explanation offered by the authors for this observation. One would think that the spinal anesthetic is still effective and the visual analog scale would be 0.

Finally, 32% of the spinal anesthesia group required ephedrine to maintain an adequate blood pressure. The spinal canal was accessed at the lumbar level between the interspace of the second and third vertebrae. It is unusual for otherwise healthy individuals to develop significant hypotension with a neuroaxial block at this level. One explanation would be propagation of the block cephalad with positioning of the patient in the reverse Trendelenburg position for operative exposure. This complication of spinal anesthesia is treated rather nonchalantly rather than as a potentially adverse event.

The majority of laparoscopic cholecystectomy procedures are performed with general anesthesia in the outpatient setting with excellent patient satisfaction. I congratulate the authors for a successful study. However, the question that is still unanswered is just because we can perform laparoscopic cholecystectomy under spinal anesthesia, should we?