Awake laparoscopic gynecological surgery under regional anesthesia: Let’s not be afraid to challenge the traditions

Dear Editor, We read with interest the article by Marrone et al. describing intermediate cervical plexus (ICP) block combined with neuraxial anesthesia for laparoscopic hernia repair.[1] Inspired by their approach, we successfully applied this technique for laparoscopic ovarian cyst resection. While laparoscopy has revolutionized surgery by offering reduced postoperative pain, shorter hospital stays, faster recovery, and lower infection rates,[2] regional anesthesia (RA) has similarly transformed anesthetic practice, particularly in high-risk patients. RA avoids airway manipulation, preserves spontaneous breathing, minimizes postoperative nausea and vomiting, enhances analgesia, and reduces opioid consumption.[3] These combined advantages support early ambulation and patient satisfaction, making RA a valuable alternative for selected laparoscopic procedures. The ICP block has recently gained attention as a promising adjunct to neuraxial anesthesia, particularly in the context of awake urological laparoscopic surgery.[4] We report a successful case of an ultrasound-guided ICP block combined with neuraxial anesthesia as a surgical anesthetic technique for laparoscopic ovarian cyst resection [Figure 1]. The patient was a 25-year-old female with a 6 cm left ovarian cyst. During the preoperative evaluation, she refused to undergo surgery unless fully awake. The patient was informed that general anesthesia is the standard approach, but she was firm in her decision. It was noted that choosing RA over general anesthesia for laparoscopic surgery required a backup plan. The patient refused sedation but consented to a laparotomic approach if pneumoperitoneum proved unsustainable and agreed to general anesthesia only in cases of severe urgency. Our anesthetic plan involved an ultrasound-guided bilateral ICP block with 10 mL of 0.15% ropivacaine per side, as previously recommended,[1] to prevent intraoperative and postoperative shoulder discomfort caused by diaphragmatic irritation from CO2 pneumoperitoneum. This was followed by subarachnoid anesthesia at L3–L4, using 9 mg of 0.5% bupivacaine, 10 mcg dexmedetomidine, and 100 mcg morphine, as we previously reported for awake laparotomy.[5] This combination provided adequate anesthesia and postoperative analgesia, particularly in case of conversion to laparotomy. The Trendelenburg position was used to achieve a T4–T5 sensory level before returning the patient to a supine position. Approximately 30 min after the ICP block, the surgery began with slow pneumoperitoneum insufflation to 9 mmHg. The surgeon reported excellent visualization of the operative field, facilitated by the patient’s slender build. The patient experienced mild shoulder discomfort (VAS 1), likely due to diaphragmatic irritation, which was resolved with 25 mcg fentanyl. The procedure lasted 32 min, during which the patient remained awake and conversing. No complications were observed. Postoperative analgesics were unnecessary, and the patient was discharged after two days.Figure 1: Ultrasound-guided regional anesthesia approach for awake laparoscopic ovarian cyst resection. Schematic representation of the anesthetic technique used for laparoscopic ovarian cyst resection without sedation. The approach included an ultrasound-guided bilateral intermediate cervical plexus block (10 mL of 0.15% ropivacaine per side) to prevent diaphragmatic irritation-related shoulder pain and subarachnoid anesthesia at the L3–L4 level (9 mg of 0.5% bupivacaine, 10 mcg dexmedetomidine, and 100 mcg morphine) to provide surgical anesthesia and postoperative analgesia. The procedure was performed with CO₂ pneumoperitoneum insufflation at 9 mmHgThe ICP block effectively alleviated shoulder pain, enabling the use of lumbar subarachnoid anesthesia with reduced risk compared to thoracic subarachnoid anesthesia and without requiring sedation. To our knowledge, this is the first reported case of fully awake laparoscopic procedure for gynecological laparoscopic surgery. While this technique shows promise, its success was likely influenced by factors such as the patient’s young age, lean body habitus, absence of significant comorbidities, short surgical duration, and the minimally invasive nature of the procedure. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.