Answer:

For laparoscopic surgery, regional anesthesia can be used. Typically, this is performed with epidural or combined spinal-epidural anesthesia, which allows for repeated dosing to obtain an adequate level and duration of anesthesia. Laparoscopic surgery requires a T4 to T5 dermatomal level. Even with adequate analgesia to this dermatome, patients will often complain of shoulder pain, which can be treated with intravenous narcotic administration. The advantages of regional anesthesia include the avoidance of instrumenting the airway, a decrease in the resultant risk of bronchospasm, and the ability to maintain the epidural postoperatively to reduce or even eliminate the need for postoperative narcotics.

However, the high level required for laparoscopic surgery has multiple effects on the respiratory system. First, patients with a high blockade lose sensory input from chest wall movement, and patients feel dyspneic, even in the presence of normal respiratory function. This feeling of dyspnea can be anxiety producing and in a patient with asthma can lead to bronchospasm.

More important, however, high levels of neuraxial anesthesia should be avoided in patients with severe respiratory disease who require accessory muscle contribution in order to maintain adequate ventilation. These patients will have reduced expiratory flow and minute ventilation under high neuraxial blockade and can become hypoxic and hypercarbic.

Newer surgical techniques, including the natural orifice transluminal endoscopic surgery (NOTES), are being developed for minimally invasive cholecystectomy. These procedures may be done with a lower dermatomal level.

• Donmez T, Erdem VM, Uzman S, et al. Laparoscopic cholecystectomy under spinal-epidural anesthesia vs. general anaesthesia: a prospective randomised study. Ann Surg Treat Res. 2017;92:136-142.
• Vretzakis G, Bareka M, Aretha D, et al. Regional anesthesia for laparoscopic surgery: a narrative review. J Anesth. 2014;28:429-446.