Epidural at T9-T10: Preoperative for HIPEC Surgery

Case Overview

Heated Intraperitoneal Chemotherapy (HIPEC) coupled with cytoreduction is increasingly being used to treat isolated peritoneal dissemination of intra-abdominal malignancies. Cytoreductive surgery (CRS) is initially performed using either a conventional open or laparoscopic approach. CRS includes removal of the main tumor, excision of any other visible tumors, peritonectomy, omentectomy, and intestinal resections, if necessary. Following CRS, a chemotherapeutic solution is administered at a temperature of 40 to 41.5 °C. Infusing chemotherapy immediately following CRS facilitates a uniform distribution of the solution throughout the entire peritoneal cavity. This strategy prevents localized spread that may arise from postoperative adhesion formation, ensuring that peritoneal surfaces are exposed to a concentrated chemotherapy dose while minimizing systemic toxicity.

This high-risk surgical procedure induces substantial hemodynamic and metabolic changes. Therefore, it requires a careful and detailed approach to the administration of anesthesia. Furthermore, hemodynamic status and cardiac function should be continuously evaluated with advanced hemodynamic monitoring. Besides primary disease and complexity of surgery, it has shown that the type and amount of fluids administered during surgery, possible blood transfusions, and the choice of anesthetic agents directly influence the outcomes experienced by patients.¹

An essential aspect of postoperative care focuses on effective pain management, which becomes particularly crucial given the severity of CRS-associated pain. The latter is associated with higher pain scores among other major abdominal surgeries.² Therefore, epidural anesthesia represents an option of critical importance for the management of these patients. The choice of initiating the epidural analgesia during surgery is tailored to the specific needs of each patient and takes into account both patient-specific factors and the specifics of the surgical technique.

This video provides a comprehensive step-by-step demonstration of the entire procedure. The epidural injection involves the delivery of anesthetic solution to the epidural space surrounding the spinal cord within the vertebral column, inducing anesthesia in the spinal segments below the site of catheter placement.

The procedure started with thorough cleaning of the patient’s back with an antiseptic solution. A 1% lidocaine solution was then administered to numb the targeted area, reducing the discomfort associated with the insertion of the epidural needle. Then the 17 G epidural needle was inserted between spinous processes of T9 and T10 vertebrae with its stylet intact and its bevel point facing cephalad. This orientation is crucial for the correct placement of the epidural catheter. The needle is then advanced through the skin, subcutaneous tissue, supraspinous, and interspinous ligaments.

Upon reaching the ligamentum flavum, the stylet was removed from the needle, and a syringe filled with saline was attached. The needle was further advanced while pressure was applied to the plunger. When the ligamentum flavum was pierced, a loss of resistance was observed, indicating that the needle had entered the epidural space.

Afterwards, 10 cc of saline was injected to expand the epidural space, a step that can reduce the risk of vascular injury. The correct positioning of the needle within the epidural space was confirmed by negative aspiration, which is the absence of cerebrospinal fluid or blood when the plunger is withdrawn. Subsequently, a catheter is threaded into the epidural space, and a test dose of the anesthetic is administered to ensure accurate placement. 

The patient is closely monitored for any adverse effects, including changes in heart rate or unusual sensations. With the successful completion of the test, blood pressure is checked, and the epidural catheter is secured, concluding this crucial phase of the preoperative procedure.

It is strongly advocated to use thoracic epidural anesthesia in cytoreductive surgery and HIPEC. This is particularly beneficial in mitigating perioperative lung function deterioration, reducing the duration of mechanical ventilation, lowering the incidence of ventilator-associated pneumonia, and shortening the stay in the intensive care unit. It also significantly improves opioid-induced and surgery-induced gut and gastric dysfunction or atonia in patients who receive supplementary thoracic epidural anesthesia.⁸

Epidural analgesia provides effective pain management and is generally well tolerated by patients undergoing CRS in conjunction with HIPEC.³ The existing evidence supports the pivotal role of epidural analgesia in reducing the incidence of chronic postsurgical pain (CPSP).⁴ The literature also highlights the superiority of epidural analgesia over alternative techniques in providing not only enhanced postoperative pain control but also a quicker recovery of bowel function, fewer side effects, greater patient satisfaction, and an overall improvement in postoperative quality of life following abdominal surgery.^5,6 An evaluation was conducted on patient satisfaction with epidural anesthesia during major abdominal surgeries using a paper questionnaire. It was found that 514 (91.4%) patients reported a good effect, while 24 (4.3%) patients reported or showed some effect, and 24 (4.3%) patients reported no effect.⁹

The successful integration of CRS and HIPEC demands a thorough, patient-centered approach, with epidural analgesia emerging as a secure and effective technique for optimizing postoperative outcomes.⁷