Feasibility of Performing Laparosopic Surgery under Spinal Anesthesia in Neonates

Katharine R Bittner, MD¹, Kaitlyn E Wong, MD¹, Maria C Mora, MD¹, Donald A Schwartz, MD², Kevin P Moriarty, MD³, Michael V Tirabassi, MD³. ¹Baystate Medical Center, Department of Surgery, ²Baystate Medical Center, Department of Anesthesiology, ³Baystate Children’s Hospital, Springfield, MA

Objective: One criticism of performing laparoscopic procedures in neonates is that general anesthesia is assumed to be required. In fragile neonates with existing cardiopulmonary disorders, such as bronchopulmonary dysplasia, it is advisable to avoid general anesthesia as these children frequently remain intubated greater than 24 hours postoperatively. In addition, there is growing concern that anesthetics may have long term neurotoxicity in children and neonates.  In this report, we present a case series of moderately complex laparoscopic procedures performed in neonates utilizing only spinal anesthesia.

 

Description and Methods: Three neonates underwent laparoscopic surgery under spinal anesthesia at a single tertiary care institution. Spinal anesthesia was performed at the levels of L3-L4 with 1mg/kg of 0.5% bupivacaine. One patient underwent laparoscopic left inguinal hernia repair via a subcutaneous endoscopically assisted ligation (SEAL) technique as previously described by Harrison, et. al. in 2005. One patient underwent laparoscopic excision of a congenital cystic mass of the liver that ultimately proved to be a simple hepatic cyst. The third patient underwent laparoscopic bilateral inguinal hernia repair and gastrostomy tube placement. Adequate exposure for these procedures was obtained with proper positioning of the bed and low insufflation pressures (6-8 mmHg). Operative times for all three procedures were under 60 minutes, allowing for adequate coverage of the procedure under spinal anesthesia (Table 1).

 

Table 1: Patient Characteristics

	Age/Sex	Birth History	Laparoscopic procedure	Additional Procedures	Operative Time	Total Time in Room	Weight on DOS
Patient 1	3 mo/ M	Premature, born at 29 weeks, bronchopulmonary dysplasia	Left inguinal hernia repair	Circumcision	38 min	99 min	3.77 kg
Patient 2	6 wk/ M	Premature, born at 31 weeks, Goldenhar syndrome	Left inguinal hernia repair, gastrostomy tube	None	45 min	93 min	2.47 kg
Patient 3	2 day/ F	Born at 38 weeks, known abdominal cyst	Hepatic cyst excision	none	57 min	98 min	2.94 kg

 

Preliminary Results: Laparoscopic insufflation was well tolerated under spinal anesthetic in these neonates.  All three patients recovered without complication. None of the children required intubation and there were no apneic or bradycardic events post-operatively.

 

Conclusion: Spinal anesthesia allowed for moderately complex minimally invasive procedures to be performed in high risk neonates. General anesthesia, therefore, may not be necessary to perform simple to moderately complex laparoscopic procedures provided the anticipated length of the procedure is within expectations for a spinal block.