Procedures
In the operating room, venous access was placed (18 G) and antibiotic prophylaxis was administered (Cefazolin 1 or 2 gr. iv, or in case of allergy, Clindamycin 600 mg iv) 30 min before skin incision, also dexamethasone 4 mg iv and midazolam 1 mg iv w administered. Vital signs were monitored: SpO2, heart rate and blood pressure every 5 minutes.
In the sitting position,in group A , RA was performed at the T9-T10 or T10-T11 level. The level of puncture was confirmed by ultrasound counting the vertebrae from the sacrum, in a caudo-cranial sense. The technique was performed in asepsis. In the subarachnoid space after the vision of clear cerebrospinal fluid (CSF) in the spinal needle 27 Gauge, without letting out the CSF, Ropivacaine 0.375% 18 mg, Sufentanyl 7 mcg, and Clonidine 20 mcg were injected. Intraoperative sedation was carried out with midazolam 0.05 mg/kg and fentanyl 1 mcg/ kg when pneumoperitoneum was performed. The anesthetic plane, suitable to the surgical procedure (T1-S4), was tested with the Pinprick and Ice test.
Group B patients undergoing GA received propofol (2 mg/kg), sufentanil (0.5 mcg/kg) and rocuronium bromide (0.6 mg/kg) for the induction of the anesthetic plane. The maintenance of the anesthetic plane was ensured with sevoflurane from 1% to 2%. Residual neuromuscular block antagonized with sugammadex 2-4 mg/kg about TOF.
The management of postoperative pain was based on the administration of Paracetamol 1000 mg in the case of VAS < 5 and the administration of Ketorolac 30 mg in the case of VAS ≥ 5.
In case of inadequate analgesia, after 60 minutes of the Ketorolac after administration, Tramadol 100 mg i.v. was administered, these patients were no longer valuable and reliable for our study.
The incidence of PONV was considered and ondansetron 4 mg i.v. was administered in case of manifestation of the complication. If after 60 minutes PONV still occurred, dexamethasone 4 mg i.v. was administered. Pneumoperitoneum induction was achieved by open laparoscopy (Hasson technique) in order to avoid the high intraperitoneal pressure, otherwise necessary for the blind insertion of the first trocar, when performing the closed technique (Veress technique). Thus, the procedure was started with a low pressure of 8mmHg and slowly increased to high flow, and pressure not higher than 11 mmHg was maintained throughout the entire surgery. Patients were placed into a minimal Trendelenburg position (maximum 20°) able to provide adequate visualization and bowel retraction. Ultrasound energy to cut and coagulate instead of monopolar/bipolar energy was used to perform salpingectomy or adnexectomy allowing to save time and reduce tissue trauma.