Commonly, laparotomy is performed under general anesthesia (GA), but in some low- and middle- income countries the lack of adequate human, technical and financial resources limits the use of GA for this purpose. An alternative to GA is regional anesthesia (RA) (spinal/epidural), which has been successfully used for abdominal operations. (1) Spinal anesthesia (SA) was advocated for emergency operations in the 1930s. (2) More recently, Kateregga et al. in their prospective study demonstrated that laparotomy performed under lumbar SA was safe and effective, and no complications were observed in their study. (3)
GA and intubation have the advantage of secured airway, but can lead to dependency on mechanical ventilation and effects such as bronchospasm, V/Q mismatch and atelectasis, and residual anesthetic or muscle relaxant effects. Additionally, GA has the highest postoperative pulmonary morbidity and mortality in upper abdominal operations due to reduced functional pulmonary residual capacity in the early postoperative period. In contrast, these effects are reduced in RA as it improves diaphragmatic function and chest wall compliance by decreasing chest wall muscle tone. (1) Rodgers et al. showed in a meta-analysis that overall mortality and other serious complications were reduced in neuraxial blockade. Altered coagulation, breathing without pain, and reduced surgical stress response have been indicated as beneficial RA mechanisms to patients. (4)
Evidence shows that RA has minimal respiratory effects even at higher level blocks, and emergency laparotomy can be safely done under SA, especially in high risk patients. (5) Utilization of SA for emergency abdominal surgery has been reported in high risk cases including uncontrolled hyperthyroidism and severe myasthenia gravis. (6, 7)
Laparoscopic procedures, including laparoscopic cholecystectomy, can also be safely performed under RA, with benefits such as reduced emesis and postoperative pain, as reported by Collins et al. Advantages of SA include no risk of intubation-related airway complications, little risk of unrecognized hypoglycemia in a diabetic patient, excellent muscle relaxation, decreased surgical bed oozing, and a more rapid return of bowel function, especially in old patients or those suffering from systemic diseases. (8, 9, 10)
Unlike GA, RA does not require aerosol generating procedures such as intubation, and thus minimizes the transmission risk of airborne infections to anesthesia and operating teams, especially in low-income countries, where proper and adequate protection is not often available. In addition, use of SA in mildly symptomatic COVID-19 patients so far is demonstrated to be safe, and according to S. A. Lie et al, RA theoretically reduces postoperative pulmonary complications in COVID-19 patients, especially those patients whose respiratory function is reduced due to pneumonia or acute respiratory distress syndrome. (11, 12)
GA requires qualified anesthesiologists/anesthetists, adequate equipment and supplies, as well as thorough perioperative care, which are lacking in most provincial and district health facilities in the Afghanistan. Due to this constraint, surgeons in these facilities often refer such patients to regional or national hospitals. This can result in treatment delays and increased morbidity and mortality.
In this study, we aimed to determine the safety and feasibility of SA for emergency laparotomy in the current context of Afghanistan to provide evidence for health policy makers to consider SA as an alternative to GA for emergency laparotomy in order to reduce referral of emergency patients, and thus reduce morbidity and mortality due to treatment delays.