ACRT Journal

Introduction

Modern surgery has been revolutionised by the laparoscopic approach, with its numerous advantages, across various specialties, from general surgery to gynecology and urology. The general anaesthesia is typically recommended for this type of surgery, even in patients with many comorbidities. To mitigate many of its effects, avoid the need for airway manipulation, and prevent the use of opioids in postoperative pain management, regional anaesthesia has also been proposed in selected cases

for laparoscopic procedures, allowing the patient to breathe spontaneously, only sedated during the surgery [1]. Prostate cancer is the commonest form of cancer in men, and surgery represents the mainstay of treatment for localised cancer in patients with good general health. A prospective comparative study revealed that laparoscopic radical prostatectomy under neuraxial anaesthesia is a feasible and safe procedure, with less postoperative pain and fewer minor complications than the same procedure under general anaesthesia, allowing muscle relaxation and respiratory mechanics without interfering with surgery [2]. Regional anesthesia, particularly neuraxial anesthesia, presents challenges that must be carefully considered, especially the risk of hypotension due to the need for extensive dermatomal coverage. For pelvic procedures, this coverage must extend from the sacral areas to C3-4 to include the phrenic nerve and prevent shoulder-tip pain, which can often worsen postoperative outcome [3].

Herein, we present the case of a patient who underwent ‘awake’ robot-assisted laparoscopic prostatectomy (RALP) for cancer, in which an intermediate cervical plexus block was added to prevent shoulder-tip pain without evidence of phrenic nerve paralysis and without complications. A sacral erector spinae plane block was performed at the end of the procedure for postoperative pain management.

Case Report

A 77-year-old patient (weight 73 Kg, height 177 cm, BMI 23 Kg.m-²), with a history of premature (extra-systolic) ventricular beats, under treatment with flecainide, ASA III, was scheduled for robot-assisted prostatectomy due to adenocarcinoma (Gleason score 6). With the patient’s written consent, a plan was devised for a combination of ultrasound-guided intermediate cervical plexus block and neuraxial (thoracic spinal) anaesthesia. Vital parameters were monitored. Three mg of intravenous midazolam were administered. Before the procedure blood pressure was 190/95 mmHg, SpO2 96%, and heart rate of 76.min^-1. Under aseptic conditions, an intermediate cervical plexus block was performed by using an echogenic 50 mm needle (UltraplexTM, B.Braun, Melsungen AG, Germany), under ultrasound guidance (EDGE II, FUJIFILM-SonositeTM, Bothwell, WA),between the sternocleidomastoid muscle and prevertebral fascia and using 0.25% levobupivacaine 8 ml plus dexmedetomidine 10 mcg (Figure 1, a). The patient was then placed in a sitting position, and under sterile conditions, after 500 ml of intravenous crystalloid infusion, a spinal anaesthesia was performed at T9 level with a 25-gauge Quincke needle via paramedian approach, injecting 0.5% levobupivacaine 2,5 ml (12.5 mg) and 0.20% hyperbaric bupivacaine 2,5 ml (5 mg) [4]. Then, under monitoring of the vital parameters, the patient was repositioned supine. After 20 minutes, a sensory block (by pinprick test and ice) was ascertained up to T2 level. No significant hemodynamic variations occurred, except for a well-tolerated episode of bradycardia (40.min^-1) that did not require medication. The patient was then introduced in the operating room, under standard monitoring, with oxygen administered via nasal cannulae at 5 L.min^-1, and intravenous sedation was initiated with propofol infusion (0.5 mg.kg^-1.h^-1). No patient’s discomfort or hemodynamic complications were noted at the moment of surgical incision and pneumoperitoneum induction (12 mmHg). Trendelenburg position (28 degrees) caused no changes in consciousness and in hemodynamics. Capnometry was used to have a more reliable insight into the patient’s ventilation and diaphragmatic function was not involved as ultrasound check demonstrated.

The surgery lasted 120 minutes and it was uneventful. The patient, during the procedure, reported drowsiness (modified Ramsay Sedation score 3-4), and dry mouth. At the end of the operation, the patient was awake, mildly dysphonic due to hoarseness (which resolved spontaneously after three hours), with hypoesthesia in the lower limbs without motor deficits. At discharge from the operating room, blood pressure was 100/74 mmHg, SpO2 96%, and HR 55.min^-1, with ALDRETE score of 9.

For the postoperative analgesia, with the patient’s informed consent, aseptically, a single-injection S1 median sacral erector spinae plane (ESP) block was performed under ultrasound guidance with the patient in lateral position, and using 80 mm echogenic needle. A solution comprising 0.25% levobupivacaine 30 ml plus dexamethasone 4 mg was injected (Figure 1, b). The patient was fed two hours after returning to the ward, mobilized in bed, and then standing after three hours.

In the following 24 hours postoperatively, the patient reported an NRS-score of 0 both at rest and during movement. He was given 1 g of intravenous paracetamol for discomfort at the surgical scars. The patient was discharged on the third day, without any complications (Clavien-Dindo 1) [5].

Figure 1: a: Cervical Plexus (transverse view). The cervical plexus emerges behind the posterior border of the sternocleidomastoid muscle. Branches of the cervical plexus can be seen superficial to the prevertebral fascia which covers the middle and anterior scalene muscles, and posterior to the sternocleidomastoid muscle. For the intermediate cervical plexus block, the injection is placed between the investing layer of the deep cervical fascia and the prevertebral fascia, the needle goes through the skin, platysma, and enveloping layer of the deep cervical fascia, with the tip placed next to the plexus. Pla, platysma muscle; SCM, sternocleidomastoid muscle; ASM, anterior scalene muscle; MSM, middle scalene muscle; EJV, external jugular vein; CP, cervical plexus; PhN, phrenic nerve; IJV, internal jugular vein; CA, carotid artery, ISB, Interscalene brachial plexus. b: Sacral Erector Spinae Plane (ESP) block involves the injection of local anaesthetic under the multifidus muscle plane, at median or intermediate sacral crest. MF, multifidus muscle.