Spinal anesthesia for vaginal and perineal surgery

The article was professionally consulted by Specialist Doctor II To Van Thai - Emergency Medicine Doctor - Emergency Resuscitation Department - Vinmec Hai Phong International General Hospital. Thai doctor has more than 34 years of experience in the field of anesthesia - emergency resuscitation.

Vaginal and episiotomy is a rather complicated surgery that requires a surgeon with experience and knowledge of the cosmetic surgery of the vaginal area. When performing the surgery, the patient does not need anesthesia, but only needs spinal anesthesia.

Vaginal and perineal plastic surgery is a solution for women who want to improve the condition of the vagina and beautify the private area. Vagina dilatation makes many women self-conscious in marital relationship; Structural deviation due to postpartum recovery, perineal surgery, uterine prolapse ....
Postpartum women who want to shrink the vagina can choose from various types of surgery such as:
Baby lip shaping. helps to reduce or reshape baby's lips Vaginal shrinkage helps to improve vaginal width creating a firm vagina and good contractions. Hymenoplasty to reconstruct the hymen as a girl Vaginal and episiotomy is a complex surgery, but does not require anesthesia. Therefore, spinal anesthesia is commonly used for vaginal and episiotomy surgery.
Spinal anesthesia is a regional anesthetic technique performed by injecting local anesthetic into the subarachnoid space to temporarily inhibit segmental nerve conduction through the nerve roots to meet the need for anesthesia for surgery. and pain relief after vaginal and episiotomy surgery
Contraindications to perform spinal anesthesia for vaginal and episiotomy surgery in the following cases:
Women refuse to perform this method Women Women who are menstruating

Anesthesia allergy Inflammation of the needle puncture site Lack of adequate circulation volume, shock Stopping anticoagulants for insufficient time Severe decompensated heart failure Mitral stenosis constricted, aortic valve constriction, ...

On the hospital side: To perform spinal anesthesia for vaginal and perineal plastic surgery, the surgical team needs doctors and nurses specializing in anesthesiology and resuscitation. At the same time, the means and tools need to be fully prepared. Specifically:
Resuscitation facilities: oxygen source, Ambu balloon, mask, endotracheal intubation equipment, anesthesia machine with breathing apparatus, electric shock machine, suction machine, ... are always available. Resuscitation drugs: fluids, drugs: ephedrine, adrenaline... Anticonvulsants: barbituric, benzodiazepines, muscle relaxants, intralipid 10-20%... Routine monitoring means: electrocardiogram, blood pressure , oxygen saturation, breathing rate. Syringes and needles of all sizes, gloves, sterile gauze, pince, antiseptic alcohol, sterile hole towels... Spinal anesthesia needles 25G or 27G. Local anesthetics: bupivacaine, levobupivacaine, ... can be combined with drugs of the morphine family, clonidine, ... Dosage is based on the patient's weight, height and physical condition; Reduce dose for people > 60 years old, anemia, pregnancy.

On the patient's side:
The patient is examined by a specialist to assess his general condition before surgery. The patient will be assigned a number of routine tests before surgery and will be examined by an anesthesiologist. Do not use aspirin-containing medicines 10 days before surgery. You need to fast for 6 hours before surgery. The ideal time of surgery is 3-5 days after menstruation and the patient is given the medicine right after the period is clear. Patients are instructed to clean the anesthetic area to avoid infection. In case, the patient is agitated, the doctor may prescribe a sedative from the day before surgery. At the same time, the patient's medical record according to the regulations of the Ministry of Health.

Prevention of hypotension: Insert an intravenous line into the patient for effective prevention of hypotension and rehydrate 0.9% sodium chloride from 5-10 ml/kg (for adults). The patient is in a sitting or lying position, usually in a supine position. If in the lying position, have the patient lie on their side with their back bent, knees pressed against the abdomen, chin pressed to the chest. If in a sitting position, the patient sits with his back arched, head bowed, chin resting on his chest, legs stretched out on the operating table or feet on the chair. The person performing spinal anesthesia needs to wear a hat, mask, wash hands, wear a shirt, wear sterile gloves and disinfect the needle puncture area in the patient 3 times.

Step 1: The doctor will perform spinal anesthesia in the midline (puncture between the 2 vertebrae, position L2-L3, L3-L4) or lateral line (1-2cm away from the midline, direct the needle into the line). middle, up, out front).
Aim the bevel of the anesthetic needle parallel to the patient's spine and insert the needle until a sensation of loss of resistance is achieved as the needle passes through the dura. Finally, to check for CSF effusion, turn the bevel of the needle toward the patient's head and inject the anesthetic.
Step 2: Inject local anesthetic bupivacaine, levobupivacaine... can be combined with morphine drugs (morphine from 100-300 mcg; fentanyl 25-50 mcg, sufentanil 2.5-5 mcg...). Dosage is based on age, weight, height and body condition: bupivacaine dose from 3-12mg; levobupivacaine from 5-12mg, reduce dose for people > 60 years old, anemia, pregnancy, ...

After surgery, patients need to monitor respiration, pulse, blood pressure, and temperature until stable according to the doctor's instructions. However, the patient needs to pay attention to post-operative care:
Keep the cutting area absolutely clean, prevent infection with physiological saline, genital betadine every day Take antibiotics, relieve pain Cut sutures after surgery 7 days surgery Avoid sex within 1 month of surgery Avoid vigorous activity

As with any medical treatment, patients undergoing spinal anesthesia for vaginal and episiotomy may experience some unwanted complications. Here are some ways to deal with the complications that the patient may experience:
When the patient is allergic, anaphylactic to local anesthetics, the anesthetic should be stopped; use anti-anaphylaxis regimen according to the Ministry of Health. It is necessary to stop using anticonvulsant sedatives, give first aid to respiratory and circulatory resuscitation, and intralipid infusion when the patient shows signs of anesthetic toxicity Lowering blood pressure, Slow pulse should be treated with vasopressors and fluid replacement. Headache: lying motionless, giving enough fluids, using pain relievers, patching the dura with autologous blood (Blood Patch). Use antiemetics when the patient feels nauseous and vomiting, and always control blood pressure Urinary retention: warm compresses, bladder catheterization if necessary. General spinal anesthesia: emergency respiratory and circulatory resuscitation. Other complications: hematoma around the spinal cord, spinal cord injury, cauda equina syndrome, meningitis. Further consultation and investigation is required to identify the lesion. Failure of anesthesia requires switching to another anesthetic method.

With the goal of bringing patients the most advanced medical techniques in the world, minimizing complications and risks, Vinmec International General Hospital has applied the ESP technique. This is an analgesia technique that can completely replace analgesia morphine in open heart surgery and thoracic surgery in both adults and children with many outstanding advantages:
Helps to relieve pain comprehensively, without complications, shorten the time of active resuscitation, eliminate the risk of postoperative pain and chronic pain in 96% of heart surgery patients. No direct effect on spinal cord and anatomical structures of nerves Safer due to ultrasound guidance There were no cases of needing to add morphine analgesia when skin incision, sternum saw. Significant reduction in the dose of painkiller Sufentanil during surgery. Pain level after extubation, exercise, and extubation (VAS <3). There were no complications of hematoma, hypotension or excessive anesthesia, respiratory depression, anesthetic toxicity.