{"paper_id":"9f416483-2afd-4204-8d32-cd4f5b9e65fe","body_text":"Vol.:(0123456789)1 3\nUpdates in Surgery (2022) 74:1755–1762 \nhttps://doi.org/10.1007/s13304-022-01310-9\nORIGINAL ARTICLE\nLaparoscopic gynecological surgery under minimally invasive \nanesthesia: a prospective cohort study\nPierluigi Giampaolino1 · Luigi Della Corte2 · Antonio Mercorio2  · Dario Bruzzese1 · Antonio Coviello3 · \nGiovanna Grasso3 · Anna Claudia Del Piano3 · Giuseppe Bifulco2\nReceived: 24 February 2022 / Accepted: 31 May 2022 / Published online: 27 June 2022 \n© The Author(s) 2022\nAbstract\nThe purpose of this study is to assess the feasibility and the perioperative outcomes of laparoscopic gynecological surgery \nin regional anesthesia (RA) from the point of view of the surgeon, anesthesiologist and patient. This is a prospective cohort \nstudy comprising sixty-six women planned to undergo gynecologic laparoscopy surgery for benign pathology at tertiary \ncare gynecolgical center of the University Federico II of Naples. Women were assigned, according to their preference, to \neither RA (Group A) or general anesthesia (GA) (Group B). Surgical, anesthesiologic and postoperative recovery data were \nrecorded. Postoperative pain was considered as the primary outcome. Secondary outcomes included mobilization, length of \nhospital stay, global surgeons and patient satisfaction, intraoperative pain assessment in Group A. Immediate postoperative \npain was significantly lower in Group A 0 vs 2 (p < 0.001), with no significant differences at 24 h. The secondary outcome \ndemonstrated early patient’s mobilization (p < 0.001) as well as early discharge (p < 0.001) and greater patient’s satisfaction \nfor the Group A. In these patients, a maximum pain score of 3 points out of 5 was recorded through the entire surgery. RA \nshowed to decrease the impact of surgical stress and to guarantee a quicker recovery without compromising surgical results. \nAlthough several surgical approaches can be employed to treat different conditions, RA technique could be a viable option \nfor well-selected patients affected by gynecological diseases.\nKeywords Gynecological surgery · Regional analgesia · Postoperative pain\nIntroduction\nOutpatient surgery, defined as the surgical patient being \nadmitted and discharged on the same day or within 24 h, is \naccountable for undoubted benefits such as satisfying patient \npreference to recover at home, lowering the risk of noso -\ncomial infection, providing cost-effectiveness, and earlier \nmobilization [1, 2]. The pursuit of accomplishing “day sur-\ngery” is one of the main goals of any surgeon [3].\nLaparoscopic procedures are commonly described as \n“minimally invasive” and the word minimal is attributed to \nsurgical trauma, pain, hospitalization interval, scar [4 ].\nRegional anesthesia (RA) from an anesthesiology per -\nspective is the “minimally invasive technique” to achieve \nanesthesia. General anesthesia (GA) is the most common \nand used technique for laparoscopic procedures, however, \nit is responsible for different adverse effects in the post-\noperative period including the need for rescue analgesics, \nand antiemetics [5, 6]. Moreover, one of the main concerns \nobserved in a patient scheduled for GA is preoperative anxi-\nety. It can be generated for the fear of the unconscious state, \nlosing control as well as the fear of awakening during the \nprocedure. In addition, GA is in the collective imagination, \nsynonymous with major surgical procedures and invasive \nhigh-risk surgeries [7, 8]. RA for the operative laparoscopic \nprocedure has been largely applied for cholecystectomy \nprocedures. It results in less surgical stress response, post-\noperative pain, lower incidence of postoperative nausea \nand vomiting, and rapid bowel canalization [9 ]. However, \n * Antonio Mercorio \n antoniomercorio@gmail.com\n1 Department of Public Health, School of Medicine, \nUniversity of Naples Federico II, Naples, Italy\n2 Department of Neuroscience, Reproductive Sciences \nand Dentistry, School of Medicine, University of Naples \nFederico II, Naples, Italy\n3 Department of Anesthesiology and Intensive Care Medicine, \nPoliclinico - Federico II University Hospital, Naples, Italy\n\n1756 Updates in Surgery (2022) 74:1755–1762\n1 3\nas regards, the gynecological domain, evidence about the \noutcomes of laparoscopy in RA are scarce. Trendelenburg \nprocedure required for the gynecological procedure, worsen-\ning pulmonary compliance and generating discomfort for the \npatient, appears to be a great limit for the application of this \ntechnique [10]. Surgical gynecological procedures, under \nRA, are currently limited to diagnostic laparoscopy adnex-\nectomy, ablation of endometriotic foci, and adhesiolysis [11, \n12]. Only one case report on total laparoscopic hysterectomy \nis reported in the literature [13]. Recently, a review by Della \nCorte et al. has shown no significant advantages to using \nSA over GA for laparoscopic treatment of gynecological \ndiseases [14].\nThe aim of our study was to assess the feasibility and the \nintraoperative and postoperative outcome of laparoscopic \ngynecological surgery under RA compared GA from the \npoint of view of the surgeon, anesthesiologist and patient.\nMaterials and methods\nThis is a prospective cohort study performed in a tertiary \nlevel referral center for minimally invasive gynecological \nsurgery. All women who were referred to our center and \nmet the inclusion criteria between January 2020 and April \n2021 were enrolled.\nInclusion criteria were: women scheduled for laparo-\nscopic surgery for benign gynecological conditions such as \novarian cyst (simple cyst, endometrioma, dermoid cyst) with \na maximum diameter ≤ 8 cm, hydro/sactosalpinx, ectopic \npregnancy (clinically stable conditions), primary/second-\nary infertility, patient carrier of BRCA mutation and aged \nmore than 18 years old. The choice of including cysts ≤ 8 cm \nhas been done to avoid cyst ruptures during manipulation of \nlarge ovaries and, so, the spread of possible neoplastic cells \nin the pelvis and abdomen. All women gave their written \ninformed consent to participate in the study. Exclusion cri-\nteria were contraindications to GA o RA, including Ameri-\ncan Society of Anesthesiologists Physical Status Classifi-\ncation System (ASA score) IV, suspected malignancy, and \nBMI > 30 kg/m2,coagulopathy (acquired, induced, genetic), \nallergy to local anesthetics, patients with suspected malig-\nnancy, uncooperative patient for psychiatrics and neurologi-\ncal disorders (such as dementia and psychosis), increased \nintracranial pressure.\nDuring the preoperative workup, all patients underwent \ngynecological examination and a detailed pelvic ultrasound \nscan was performed by an expert sonographer, eventually, \nMRI was performed to accurately define the characteristics \nof the lesion. Women were invited to participate in the study \nduring the preoperative examination. After detailed and \nextensive counseling by the surgeon as well as by two anes-\nthesiologists (AC and GG), with expertise about anesthesia \nin laparoscopic surgery and clinical and practical implication \nof both GA and RA, informed written consent was obtained \nand patient were allocated to one of the two groups accord-\ning to their preferences.\nSeventy patients were initially analyzed, but 66 patients \nsatisfied the inclusion criteria and were enrolled in the study: \n36 in Group A, 30 in Group B.\nAll the procedures were performed by a single operator \n(PG) with expertise in laparoscopic gynecological surgery \nwho performed more than 100 procedures per year. The \nentire procedure was performed so that the patient could \nbe invited to follow the entire procedure. A high-resolution \ncolor video screen was provided to show the intraoperative \nimages. In group A, patients were informed about every sin-\ngle step of the intervention by both the surgeon and anesthe-\nsiologist. During each phase, patients were asked to score \nthe pain using a Likert scale from 1 to 5.\nBaseline demographic and clinical data of the patients \nincluded in the study as well as the intraoperative surgical \nand anestesiologic variables were recorded.\nPostoperative pain assessed through Visual analog scale \n(VAS) was the primary outcome. The main secondary out-\ncomes included: postoperative nausea and vomiting (PONV) \nand antiemetic/analgesic drugs usage. Further secondary \noutcomes were anesthesia complications, resumption of \nbowel motility, time to mobilization, global surgeons and \npatient satisfaction, length of hospital stay, intraoperative \npain in RA group through Likert scale.\nIn the operating room, venous access was placed (18 G) \nand antibiotic prophylaxis was administered (Cefazolin 1 or \n2 gr. iv, or in case of allergy, Clindamycin 600 mg iv) 30 min \nbefore skin incision, also dexamethasone 4 mg iv and mida-\nzolam 1 mg iv w administered. Vital signs were monitored: \nSpO2, heart rate and blood pressure every 5 min.\nIn the sitting position, in group A, RA was performed \nat the T9-T10 or T10-T11 level. The level of puncture was \nconfirmed by ultrasound counting the vertebrae from the \nsacrum, in a caudo-cranial sense. The technique was per -\nformed in asepsis. In the subarachnoid space after the vision \nof clear cerebrospinal fluid (CSF) in the spinal needle 27 \nGauge, without letting out the CSF, Ropivacaine 0.375% \n18 mg, Sufentanyl 7 mcg, and Clonidine 20 mcg were \ninjected. Intraoperative sedation was carried out with mida-\nzolam 0.05 mg/kg and fentanyl 1 mcg/kg when pneumop-\neritoneum was performed. The anesthetic plane, suitable to \nthe surgical procedure (T1-S4), was tested with the Pinprick \nand Ice test.\nGroup B patients undergoing GA received propofol \n(2 mg/kg), sufentanil (0.5 mcg/kg) and rocuronium bro-\nmide (0.6 mg/kg) for the induction of the anesthetic plane. \nThe maintenance of the anesthetic plane was ensured with \nsevoflurane from 1 to 2%. Residual neuromuscular block \nantagonized with sugammadex 2–4 mg/kg about TOF. \n\n1757Updates in Surgery (2022) 74:1755–1762 \n1 3\nThe management of postoperative pain was based on \nthe administration of Paracetamol 1000 mg in the case of \nVAS < 5 and the administration of Ketorolac 30 mg in the \ncase of VAS ≥ 5.\nIn case of inadequate analgesia, after 60 min of the \nKetorolac after administration, Tramadol 100 mg i.v. was \nadministered.\nThe incidence of PONV was considered and ondansetron \n4 mg i.v. was administered in case of manifestation of the \ncomplication. If after 60 min PONV still occurred, dexa-\nmethasone 4 mg i.v. was administered. Pneumoperitoneum \ninduction was achieved by open laparoscopy (Hasson tech-\nnique) to avoid the high intraperitoneal pressure, otherwise \nnecessary for the blind insertion of the first trocar, when \nperforming the closed technique (Veress technique), and \nto prevent inferior epigastric artery damage [15]. Thus, the \nprocedure was started with a low pressure of 8 mmHg and \nslowly increased to high flow, and pressure not higher than \n11 mmHg was maintained throughout the entire surgery. \nPatients were placed into a minimal Trendelenburg position \n(maximum 20°) able to provide adequate visualization and \nbowel retraction. Ultrasound energy to cut and coagulate \ninstead of monopolar/bipolar energy was used to perform \nsalpingectomy or adnexectomy allowing to save time and \nreduce tissue trauma.\nStatistical analysis\nAll statistical analyses were conducted using the statistical \nPlatform R (vers. 4.0.1).\nSample characteristics were reported using standard \ndescriptive statistics. Mean ± standard deviation (min to \nmax) in case of numerical variables and absolute frequencies \nand percentages in case of categorical factors. Numerical \nvariables showing highly skewed distribution were described \nusing median with interquartile range (25th–75th percen -\ntile). Accordingly, between-group comparisons were based \non the t-test or the Mann–Whitney U test in case of numeri-\ncal variables and the chi-square test or the Fisher exact test \nin case of categorical outcome. No correction for multiple \ncomparisons was undertaken when analyzing longitudinal \noutcomes (VAS score and analgesic intake).\nA sample size of 30 patients for group was deemed suf-\nficient to highlight a large effect size (d = 0.8) with a power \nof 0.8 and a two-sided significance level of 0.05, using a \nWilcoxon-Mann–Whitney U test on the primary outcome \nrepresented by the VAS score after 24 h from surgery.\nResults\nAll selected patients underwent surgical laparoscopy under \nregional (Group A) or general (Group B) anesthesia.\nBaseline demographic and clinical data of the patients \nincluded in the study did not show significant differences \nbetween the two groups (Table  1).\nAmong the gynecological benign diseases, most of the \npatients had a simple ovarian cyst (43/66, 65.2%) in particu-\nlar among Group B (26/30, 86.7%). No patient who under -\nwent general anesthesia had sterility, ectopic pregnancy or \nBRCA1/2 mutation as surgical indication. Considering the \ntype of intervention, although a statistically significant dif-\nference emerged between the two groups, this difference was \nnot clinically relevant. No patients required laparotomic or \nanesthesia conversion and in no case accessory ports, in \naddition to the conventional four scheduled, were needed.\nThe degree of Trendelenburg’s position was similar in the \ngroups: 16.3 ± 3 in Group A vs. 16.7 ± 2.8 degrees in Group \nB (p = 0.609). Also, operative time was not significantly dif-\nferent between the two groups (58.2 ± 24.8 in group A vs. \n65 ± 24.4 min in group B, p = 0.267).\nRegarding the postoperative pain (Table  2), the VAS \nscore showed a change from 0 to 24 h (h): indeed, it was \nsignificantly lower in Group A up to 6 h [0 (0–0.8) vs 2 \n(1–5)], p < 0.001 in the immediate postoperative period and \n(1.5 (0–2.8) vs 3 (1–5), p  0.004 at 6 h) with an inversion at \n18 h (2 (0.2–5.2) vs 0.5 (0–3), p  0.02) for Group B, and no \nstatistically significant differences between the two groups \nat 24 h. Figure  1 reports the VAS score trend during the \nobservation time (0–24 h). Analyzing the intake of anal-\ngesics after surgery, no differences were observed among \nthe type of analgesic (paracetamol, ketorolac and tramadol) \nand during the post-operative observation time, except for \nparacetamol at 0 h, with a significant difference between \nthe two groups (0 (0) vs 6 (20), (p  = 0.007). In Table  3 are \nreported the secondary outcomes such as anesthesia related \ncomplications, resumption of bowel motility, patient’s mobi-\nlization, surgeons global satisfaction (the surgical team at \nthe end of the procedure was asked about global satisfaction \nin term of pelvic organ exposure and ability to perform the \nprocedure in relation to the anesthesia used), patient satisfac-\ntion (patients were asked to answer a closed-ended question \nupon discharge: would you do the same anesthesia again?), \nlength in hospital stay. A faster resumption of bowel motil-\nity (7.1 ± 1.1 vs 13 ± 1.2, p < 0.001) and patient’s mobiliza-\ntion (2.9 ± 0.6 vs 6.7 ± 1.4, p < 0.001) and an early discharge \n(17.9 + 1.4 vs 23.8 ± 1.8, p < 0.001) were observed in Group \nA compared to Group B. No significant differences were \nrecorded in term of PONV.\nConcerning anesthetic complications, we registered two \ncases of intraoperative hypotension (one for each group), \nmanaged with intravenous saline infusion, and only one case \nof bradycardia in group A. Two post-operative complications \nwere recorded (according to Clavien-Dindo Classification I): \none urinary tract infection (Group A) and one urinary reten-\ntion (Group B) resolved with intermittent catheterization.\n\n1758 Updates in Surgery (2022) 74:1755–1762\n1 3\nFinally, we reported for Group A the pain score obtained \nwith the Likert scale, classically divided into 5 points (0: no \npain, 5: maximum pain) during the various stages of sur -\ngery: introduction of uterine manipulator, introduction Has-\nson trocar and induction of pneumoperitoneum; introduc-\ntion of ancillary trocars; exploration of pelvic organs; actual \nsurgical procedure; skin suture. As reported in Table  4, all \npatients showed a pain score of 1 or 2, with only 3 cases \n(7.9%) with a score of 3 during the skin suture.\nDiscussion\nOur data confirm the suitability of laparoscopy surgery \nunder RA for gynecological surgery, a still debated subject \nin literature, in contrast to general surgery of which success-\nful results are already reported in literature [14– 18].\nIndeed, no need for laparotomic or general anesthesia \nconversion was required.\nBased on our results, less pain was registered in RA group \nespecially in the first postoperative hours. In addition, RA \nproved to lead to a quick recovery in terms of mobilization, \nresumption of bowel motility, length of hospital stays and \nwas well accepted by both patients and surgeons.\nAlthough we are fully aware that no other studies like \nrandomized controlled trials can minimize bias and pro-\nvide a rigorous tool to examine cause-effect relationships \nbetween intervention and outcome, our study was conceived \nand designed as a prospective study. We believe, indeed, \nthat patient’s motivation and willingness to accomplish sur-\ngery under RA are key aspects for the accomplishment of \nthe procedure therefore, in our opinion, randomization of \npatients at the moment has to be considered counterintuitive \nand challenging.\nStrengths of our study were the sample size (the largest \nreported so far in literature), the accomplishment of all the \nprocedures by one skilled surgeon and the assessment of the \ntolerability and the evaluation of the pain during each step of \nlaparoscopy (to determine the acceptability of the procedure \nwhen performed under regional anesthesia). We consider \nthis latter of paramount importance based on the assump-\ntion that sedation should be avoided as much as possible \nto preserve spontaneous breathing already restricted by the \nlevel of neuraxial anesthesia and Trendelenburg’s position.\nAn adequate and lasting post-operative pain control is \ncrucial to enhance recovery [19]. Regarding postoperative \npain, our result confirms the findings already registered in \nlaparoscopy cholecystectomy under RA: less pain is regis-\ntered especially in the first postoperative hour [16, 20, 21] \nand this can be considered of foremost importance as long \nas the early onset of pain right after surgery is capable to \naffect the whole recovery phase [ 19]. This result might be \nexplained by the persistent neuraxial blockade. To enhance \nthis effect in our study clonidine was administered to the \nTable 1  Patient’s characteristics \nBMI Body Mass Index; ASA American Society of Anesthesiologists\nOverall (n = 66) Group A (n = 36; 54.5%) Group B (n = 30; 45.5%) p value\nAge (years) 39 ± 16.1 (18–85) 39.9 ± 7.8 (27–52) 37.8 ± 22.4 (18–85) 0.625\nBMI 23.7 ± 2.8 (19–30.5) 23.2 ± 2.4 (20.6–27) 24.3 ± 3.2 (19–30.5) 0.105\nComorbidity 23 (34.8) 13 (36.1) 10 (33.3) 1\n Hypertension 5 (7.6) 1 (2.8) 4 (13.3)\n Thyroid disease 6 (9.1) 3 (8.3) 3 (10)\n Diabetes 3 (4.5) 3 (8.3) 0 (0)\n Other 9 (13.6) 6 (16.7) 3 (10)\nASA 0.084\n I 18 (27.3) 6 (16.7) 12 (40)\n II 42 (63.6) 27 (75) 15 (50)\n III 6 (9.1) 3 (8.3) 3 (10)\nGynecological disease 0.003\n Ovarian cyst 43 (65.2) 17 (47.2) 26 (86.7)\n Endometrioma 6 (9.1) 3 (8.3) 3 (10)\n Sactosalpinx 5 (7.6) 4 (11.1) 1 (3.3)\n Sterility 3 (4.5) 3 (8.3) 0 (0)\n Ectopic pregnancy 3 (4.5) 3 (8.3) 0 (0)\n BRCA mutation 6 (9.1) 6 (16.7) 0 (0)\nTrendelenburg’s position (degree) 16.5 ± 2.9 16.3 ± 3 16.7 ± 2.8 0.609\nOperative Time (minutes) 61.3 ± 24.7 58.2 ± 24.8 65 ± 24.4 0.267\n\n1759Updates in Surgery (2022) 74:1755–1762 \n1 3\npatient who underwent RA. Clonidine is an α2 adrenergic \nagonist used like an adjuvant in anesthesia. There were dif-\nferent possible mechanisms to explain the enhanced anes-\nthetic efficiency. According to some researchers, the action \nof α2-agonism of clonidine induces vasoconstriction, which \nmight contribute to prolonging the analgesia time. Further -\nmore, clonidine potentiates the spinal block via synergis-\ntic interaction between α2 receptors and sodium channels, \nresulting in a reduction in the dose of the local anesthetics \nrequired for achieving effective spinal anesthesia for certain \nsurgical procedures [22, 23].\nDuration of surgery for women who underwent RA was \ncomparable to the control group and the whole surgical \nteam, questioned about pelvic organ exposure at the end of \nthe procedure, gave in agreement positive feedback. These \ndata, in particular, are encouraging given that one of the \nmain concerns regarding the execution of this anesthesia \nfor gynecological laparoscopic procedure is the difficulty \nto achieve a sufficient degree of Trendelenburg’s position \n(a key factor in gynecological surgery to retract bowel and \nprovide adequate visualization) providing at the same time \nadequate ventilation. In our study, the degree of Trendelen-\nburg’s position obtained in RA group was only 16.33 ± 2.97. \nNo case of hypercapnia or pulmonary complication was \nregistered.\nRA compared with GA showed a quick recovery in the \nimmediate postoperative setting. Enhanced Recovery After \nSurgery (ERAS) Protocols encourage the early mobilization \nof the patients [24 ]. Our data, according to the literature, \ndemonstrate a significantly earlier mobilization in RA group \ncompared to patient underwent general anesthesia. This \nfinding together with the faster resumption of bowel move-\nment, equally founded to be statistically significant in the RA \ngroup, is of particular interest in childbearing age women for \nthe preventive effect on post-surgical adhesion formation (a \nproven factor for infertility disorders) [25]. GA has long been \nconsidered as causing a greater frequency and severity of \nPONV than regional anesthetic techniques [26]. In our study, \npatients in the RA group showed a lower incidence of PONV \nand required fewer drugs to avoid it, although these results \nwere no statistically significant. Two previous studies evalu-\nating PONV among gynecological patients treated with lapa-\nroscopy surgery with RA and GA showed discordant results. \nRaimondo et al. reported a higher incidence rate of PONV \nin women that received GA whereas Zirak et al. revealed \nthis complication to be more frequent in the RA group [10, \nTable 2  Primary outcome\nVAS Visual Analog Scale, NA not applicable\nOverall (n = 66) Group A (n = 36; 54.5%) Group B (n = 30; 45.5%) p value\nVAS score\n 0 h 1 (0–1) 0 (0–0.8) 2 (1–5)  < 0.001\n 6 h 2 (0–4) 1.5 (0–2.8) 3 (1–5) 0.004\n 12 h 3 (0–5) 3 (0–5) 2.5 (0–5) 0.877\n 18 h 2 (0–3) 2 (0.2–5.2) 0.5 (0–3) 0.02\n 24 h 0.5 (0–3) 0.5 (0–4.5) 0.5 (0–3) 0.714\nAnalgesics intake\n Paracetamol 1 g\n  0 h 6 (9.1) 0 (0) 6 (20) 0.007\n  6 h 9 (13.6) 3 (8.3) 6 (20) 0.28\n  12 h 12 (18.2) 6 (16.7) 6 (20) 0.758\n  18 h 9 (13.6) 3 (8.3) 6 (20) 0.28\n  24 h 12 (18.2) 6 (16.7) 6 (20) 0.758\n Ketorolac 30 mg\n  0 h 6 (9.1) 3 (8.3) 3 (10) 1\n  6 h 3 (4.5) 0 (0) 3 (10) 0.089\n  12 h 0 (0) 0 (0) 0 (0) NA\n  18 h 0 (0) 0 (0) 0 (0) NA\n  24 h 12 (18.2) 6 (16.7) 6 (20) 0.758\n Tramadol 100 mg\n  0 h 0 (0) 0 (0) 0 (0) NA\n  6 h 0 (0) 0 (0) 0 (0) NA\n  12 h 3 (4.5) 0 (0) 3 (10) 0.089\n  18 h 0 (0) 0 (0) 0 (0) NA\n  24 h 0 (0) 0 (0) 0 (0) NA\n\n1760 Updates in Surgery (2022) 74:1755–1762\n1 3\nFig. 1 VAS score trend during the observation time in the two groups (0 to 24 h)  \nTable 3  Secondary outcomes\nOverall (n = 66) Group A (n = 36; 54.5%) Group B (n = 30; 45.5%) p value\nAnesthesia complications 3 (4.5) 2 (5.5) 1 (3.3) 0.245\nPONV (no. (%))\n No 39 (59.1) 24 (66.7) 15 (50) 0.213\n Yes 27 (40.1) 12 (33.3) 15 (50)\nAntiemetic drugs (No. patients) 9 (13.6) 3 (8.3) 6 (20) 0.280\nResumption of bowel motility (h) 9.8 ± 3.2 (5 to 15) 7.1 ± 1.1 (5 to 9) 13 ± 1.2 (11 to 15)  < 0.001\nLength of hospital stay (h) 20.8 ± 3.4 (15 to 28) 17.9 ± 1.4 (15 to 21) 23.8 ± 1.8 (21 to 28)  < 0.001\nMobilization (h) 4.6 ± 2.2 (2 to 9) 2.9 ± 0.6 (2 to 4) 6.7 ± 1.4 (4 to 9)  < 0.001\nGlobal surgeon satisfaction 0.136\n Good 3 (4.5) 0 (0) 3 (10)\n Very good 12 (18.2) 6 (16.7) 6 (20)\n Excellent 51 (77.3) 30 (83.3) 21 (70)\nGeneral patient satisfaction (would you \ndo the same anesthesia again?)\n63 (95.5) 36 (100) 27 (90) 0.089\n\n1761Updates in Surgery (2022) 74:1755–1762 \n1 3\n27]. This divergence could be explained by the presence of a \nconfounding factor, the inflation during laparoscopy, which \ncan be considered by itself a cause of PONV [28, 29].\nAlthough our study was not focused on cost analysis, \nbased on our results we can globally consider RA a cost \nsaving alternative to GA, in accordance with Turkstani \net al. (who instead performed an accurate comparison of \nanesthesia cost about spinal versus general anesthesia for \nlaparoscopic cholecystectomy) [30], taking in consideration \nthe reduced amount of drugs used for our patients in the \npostoperative time and the earlier discharge.\nGreat motivation for the patient is mandatory to accom-\nplish this technique and patient anxiety must be addressed \nbefore surgery with appropriate counseling but communica-\ntion with an empathetic anesthesiologist and surgeon just \nduring surgery may help significantly to reduce patients' \nanxiety. In this regard, we considered it essential to inform \nthe patient about each step of the surgery (showing on \nrequest the live procedure on the screen) and obtain his \nfeedback even during surgery.\nConsidering all the steps, a maximum of 2 points on the \nLikert scale (considered a mild pain) was recorded: only 3 \ncases with a score of 3 during skin suture were registered.\nFinally, another important advantage of RA, to not be \nunderestimated during the ongoing COVID-19 pandemic, \nis the avoidance of airway management that can prevent \nthe risk of virus spread [31].\nConclusions\nBased on the aforementioned results we consider RA a valid \nalternative to GA for laparoscopic gynecological surgery: \nin accordance with the goals of the minimally invasive \nsurgery era, RA demonstrated to decrease the impact of \nsurgical stress and to guarantee a quicker recovery with-\nout compromising, at the same time, surgical outcomes. \nAs well as different surgical approaches could be selected \nbased on patients characteristics and diseases, accordingly, \nanesthesia’s technique should be tailored on patients motiva-\ntions and conditions. However, further studies are required \nto evaluate more complex and longer surgical procedures.\nAcknowledgements Vitale SG, Gasbarro N, Lagana AS, Sapia F, \nRapisarda AMC, Valenti G, Trovato MA, Rossetti D, Chiofalo B, Bar-\nrasso G, Tinelli A, Corrado F. Safe introduction of ancillary trocars in \ngynecological surgery: the “yellow island” anatomical landmark. Ann \nItal Chir. 2016;87:608-611. PMID: 27909270.\nAuthor contributions  All the authors conform to the International \nCommittee of Medical Journal Editors (ICMJE) criteria for author -\nship, contributed to the intellectual content of the study. PG, AM and \nLDC conceptualized the study. PG performed laparoscopic surgery. \nGG, ADP, AC performed anesthesia. DA, AM, LDC managed the data \nset and performed statistical analyses. GB and PG gave approval for the \nfinal version of the article.\nFunding Open access funding provided by Università degli Studi di \nNapoli Federico II within the CRUI-CARE Agreement. This research \ndid not receive any specific grant from funding agencies in the public, \ncommercial, or not-for-profit sectors.\nData availability The datasets generated during the study are available \nfrom the corresponding author on reasonable request.\nDeclarations \nConflict of interest The authors have no relevant financial or non-fi-\nnancial interests to disclose.\nEthical approval In accordance with the Declaration of Helsinki all \npatients signed a written detailed informed consent prior to the inclu-\nsion in the study. The study received ethical approval from the local \nresearch ethics committee of the University of Naples Federico II on \nJune 2019 (protocol number: 75/19).\nConsent to participate Informed consent was filled out as required for \nthe execution of this study.\nHuman participants and/or animals All procedures performed in stud-\nies involving human participants were in accordance with the ethical \nstandards of the institutional and/or national research committee and \nwith the 1964 Helsinki declaration and its later amendments or com-\nparable ethical standards.\nOpen Access This article is licensed under a Creative Commons Attri-\nbution 4.0 International License, which permits use, sharing, adapta-\ntion, distribution and reproduction in any medium or format, as long \nas you give appropriate credit to the original author(s) and the source, \nprovide a link to the Creative Commons licence, and indicate if changes \nwere made. The images or other third party material in this article are \nincluded in the article's Creative Commons licence, unless indicated \notherwise in a credit line to the material. If material is not included in \nthe article's Creative Commons licence and your intended use is not \npermitted by statutory regulation or exceeds the permitted use, you will \nTable 4  Likert scale in Group A\nLikert scale Value (0–5) Number \nof patients \n(%)\nIntroduction of uterine manipulator 1 33 (100%)\nintroduction of Verres needle 1 36 (100%)\nintroduction of Hasson and ancillary \ntrocars\n1 36 (100%)\ninduction of pneumoperitoneum 1\n2\n27 (75%)\n9 (25%)\nExploration of pelvic organs 1\n2\n35 (92.1)\n3 (7.9)\nActual surgical procedure 1\n2\n33 (84.6)\n6 (15.4)\nSkin suture 1/2\n3\n35 (92.1)\n3 (7.9)\n\n1762 Updates in Surgery (2022) 74:1755–1762\n1 3\nneed to obtain permission directly from the copyright holder. 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