Epidural anesthesia for laparoscopic bariatric surgery: a case report

BACKGROUND: Rapid and uneventful postoperative recovery following general anesthesia in morbidly obese patients undergoing bariatric surgery may offer challenges to anesthesiologists. With improved surgical techniques and shorter pneumoperitoneum, regional anesthesia may be considered for this laparoscopic procedure in selected cases. CASE DESCRIPTION: The first patient was a 60-year-old male (body mass index: 39 kg/m(2)) who was scheduled for laparoscopic sleeve gastrectomy. The second patient was a 46-year-old female (body mass index: 47 kg/m(2)) who was scheduled for laparoscopic gastric bypass. After standard intraoperative monitoring was applied, epidural anesthesia was performed at thoracic level T9–T10. Surgical technique modification included insufflation of CO(2) at a low flow rate and avoidance of orogastric tube use. During the procedure, both patients breathed spontaneously without difficulty. One hypotension episode occurred and was successfully treated with a 12-mg bolus of ephedrine in case 1. Shoulder pain occurred intraoperatively in case 2 and was successfully treated with a 50-μg bolus of fentanyl. Postoperatively, 2 mg epidural morphine was administered for postoperative analgesia. Both patients were satisfied with the anesthesia technique and was discharged uneventfully. DISCUSSION AND EVALUATION: This anesthetic technique may maintain pre-operative respiratory function, increase alertness, and reduce the use of rescue analgesics, which is crucial for optimal outcomes in morbidly obese patients. Conversion of epidural anesthesia to general anesthesia may be required if patients can not tolerate the laparoscopic procedure (e.g. intolerable shoulder pain) or the increased respiratory rate during pneumoperitoneum leading to difficulty in performing laparoscopic surgery. Further studies are needed to elucidate this issue. CONCLUSIONS: General anesthesia is widely used for laparoscopic bariatric surgery, but epidural anesthesia may be a viable alternative to general anesthesia in selected cases. Further prospective studies may be required to elucidate the relative advantages and disadvantages of epidural anesthesia in this surgical population.