First Report of Hepatectomy without Endotracheal General Anesthesia

BACKGROUND: Local anesthesia, including epidural anesthesia, has much merit over general anesthesia for the reduction of perioperative cardiac and respiratory complications. Liver operations commonly require general anesthesia. This is the first report of hepatectomy performed under epidural anesthesia with conscious sedation to avoid general anesthesia with endotracheal intubation. STUDY DESIGN: We devised the following protocol for hepatectomy under epidural anesthesia with conscious sedation: the patient receives 10 mg diazepam orally 1 hour before surgery, followed by 10 mg diazepam and 15 mg pentazocine intravenously just before surgery. An epidural catheter is inserted via the thoracic vertebra 7 to 9 interspaces. Intraoperatively, the patient receives a bolus of 7 mL 2% mepivacaine hydrochloride every 40 minutes through the epidural catheter. We conducted 4 left hepatectomies, 1 left lateral sectorectomy, and 5 partial hepatectomies under this protocol. We assessed the efficacy and safety of hepatectomy under epidural anesthesia with conscious sedation in terms of mortality rate, surgical time, amount of bleeding, and central venous pressure during the procedure. RESULTS: Every patient was managed without endotracheal intubation and laryngeal masks. There was no perioperative mortality. Median intraoperative blood loss was 453.0 mL (range 144.0 to 1292.0 mL) and median surgical time was 273.0 minutes (range 137.0 to 440.0 minutes). Median total amount of 2% mepivacaine hydrochloride used was 52.0 mL (range 23.0 to 95.0 mL). Central venous pressure values were significantly lower during the Pringle maneuver than at preclamp. CONCLUSIONS: The traditional belief is that liver resection should be performed under general anesthesia. We report the world's first series of liver resections for malignant tumors performed under epidural anesthesia with conscious sedation to avoid general anesthesia with endotracheal intubation. ((c) 2013 by the American College of Surgeons)