Laparoscopic Cholecystectomy Under Spinal Anesthesia in Patients with Multiple Comorbidities: A Cohort Study

Laparoscopic Cholecystectomy Under Spinal Anesthesia in Patients with Multiple Comorbidities: A Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Laparoscopic Cholecystectomy Under Spinal Anesthesia in Patients with Multiple Comorbidities: A Cohort Study Fayaz Ahmad Najar, Sheema Bashir, Zahid Majeed Nadaf, Arshad Rashid, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7801682/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Patients with multiple comorbidities undergoing laparoscopic cholecystectomy face increased perioperative risks with general anesthesia. Spinal anesthesia may offer a safer alternative in this high-risk population. Objective To evaluate the feasibility, safety, and efficacy of laparoscopic cholecystectomy under spinal anesthesia in patients with multiple comorbidities. Methods This prospective observational study included 97 patients with multiple comorbidities (ASA II-IV) scheduled for elective laparoscopic cholecystectomy. Spinal anesthesia was performed using 0.5% hyperbaric bupivacaine (12.5–15 mg) with fentanyl (25 µg). Primary outcomes included feasibility of procedure completion and conversion rates to general anesthesia. Secondary outcomes encompassed hemodynamic stability, pain scores, recovery parameters, and patient satisfaction. Results Laparoscopic cholecystectomy was successfully completed under spinal anesthesia in 89 patients (91.8%). Eight patients (8.2%) required conversion to general anesthesia, primarily due to severe shoulder pain (50%) and patient anxiety (25%). No mortality occurred. Hypotension developed in 24 patients (24.7%) and was effectively managed. Mean postoperative VAS pain scores were 2.1 ± 1.4 at 2 hours. Median time to mobilization was 4.2 hours, and 42 patients (43.3%) were eligible for same-day discharge. Patient satisfaction scores averaged 8.4 ± 1.6 out of 10. Patients with higher comorbidity burden (Charlson Comorbidity Index ≥ 5) had similar success rates but slightly higher conversion rates (10.7% vs 4.9%, p = 0.284). Conclusion Laparoscopic cholecystectomy under spinal anesthesia is feasible and safe in carefully selected patients with multiple comorbidities, offering superior pain control, faster recovery, and high patient satisfaction with acceptable conversion rates. Laparoscopic cholecystectomy spinal anesthesia comorbidities regional anesthesia minimally invasive surgery high-risk patients perioperative outcomes patient safety Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Laparoscopic cholecystectomy has become the gold standard treatment for symptomatic gallstone disease and acute cholecystitis due to its minimally invasive nature, reduced postoperative pain, shorter hospital stay, and faster recovery compared to open cholecystectomy ( 1 , 2 ). However, the management of patients with multiple comorbidities undergoing this procedure presents unique challenges, particularly in the choice of anesthetic technique. Traditionally, laparoscopic cholecystectomy is performed under general anesthesia with endotracheal intubation to ensure adequate ventilation and patient safety during pneumoperitoneum creation ( 3 , 4 ). The insufflation of carbon dioxide into the peritoneal cavity creates increased intra-abdominal pressure, which can compromise respiratory mechanics and cardiovascular function, necessitating controlled ventilation ( 5 ). However, general anesthesia may pose significant risks in patients with multiple comorbidities, including cardiovascular disease, chronic obstructive pulmonary disease, diabetes mellitus, and obesity ( 6 , 7 ). Patients with multiple comorbidities often present with increased perioperative morbidity and mortality when subjected to general anesthesia ( 8 , 9 ). These patients may have compromised cardiac function, reduced pulmonary reserve, altered drug metabolism, and increased susceptibility to postoperative complications such as respiratory depression, cardiovascular instability, and delayed recovery ( 10 , 11 ). The physiological stress of general anesthesia combined with the hemodynamic changes associated with pneumoperitoneum can exacerbate existing medical conditions and lead to adverse outcomes ( 12 , 13 ). Spinal anesthesia, a well-established neuraxial technique, offers several potential advantages in high-risk patients ( 14 , 15 ). It provides excellent analgesia, reduces the need for systemic analgesics, maintains patient consciousness, preserves protective airway reflexes, and minimizes the risk of aspiration ( 16 , 17 ). Additionally, spinal anesthesia can reduce the incidence of postoperative nausea and vomiting, deep vein thrombosis, and pulmonary complications compared to general anesthesia ( 18 , 19 ). The application of spinal anesthesia for laparoscopic procedures has gained increasing attention in recent years, with several studies demonstrating its feasibility and safety in selected patients ( 20 , 21 ). However, the use of spinal anesthesia for laparoscopic cholecystectomy remains controversial due to concerns about patient comfort during pneumoperitoneum, adequate muscle relaxation, and the potential need for conversion to general anesthesia ( 22 , 23 ). The pneumoperitoneum-induced diaphragmatic irritation and shoulder pain can be challenging to manage with regional anesthesia alone ( 24 ). Despite these challenges, emerging evidence suggests that spinal anesthesia may be a viable alternative to general anesthesia in carefully selected patients, particularly those with significant comorbidities who are at high risk for general anesthesia-related complications ( 25 , 26 ). The technique requires careful patient selection, optimal positioning, appropriate local anesthetic dosing, and meticulous monitoring of hemodynamic parameters ( 27 , 28 ). This study aims to evaluate the feasibility, safety, and efficacy of laparoscopic cholecystectomy performed under spinal anesthesia in patients with multiple comorbidities, comparing perioperative outcomes, complication rates, and patient satisfaction with traditional general anesthesia approaches. Understanding the role of spinal anesthesia in this high-risk population may provide valuable insights for optimizing perioperative care and reducing anesthesia-related morbidity in patients with complex medical histories. MATERIALS AND METHODS Study Design and Setting This was a prospective observational study and was conducted between January 2016 to December 2021. The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines (29,30). Patient Selection and Eligibility Criteria Inclusion Criteria Patients were included if they met the following criteria: Age 18-75 years American Society of Anesthesiologists (ASA) physical status II-IV Scheduled for elective laparoscopic cholecystectomy Presence of multiple comorbidities defined as two or more of the following: cardiovascular disease, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, obesity (BMI >30 kg/m²), or hypertension Ability to provide informed consent Exclusion Criteria Patients were excluded if they had: Contraindications to spinal anesthesia (coagulopathy, local infection, patient refusal, severe spinal deformity) Emergency surgery Acute cholangitis or severe acute cholecystitis with sepsis Previous abdominal surgery with extensive adhesions Pregnancy Severe cardiopulmonary disease (NYHA Class IV, severe COPD with FEV1 <30%) Psychiatric disorders preventing cooperation Preoperative Assessment All patients underwent comprehensive preoperative evaluation including detailed medical history, physical examination, and relevant investigations. The Charlson Comorbidity Index was calculated to quantify the burden of comorbid conditions (31). Preoperative investigations included complete blood count, comprehensive metabolic panel, coagulation studies, electrocardiography, chest radiography, and echocardiography when indicated. Pulmonary function tests were performed in patients with respiratory comorbidities (32). Risk stratification was performed using validated scoring systems including ASA physical status classification, Goldman Revised Cardiac Risk Index, and STOP-BANG questionnaire for obstructive sleep apnea screening (33,34,35). All patients were counseled about the anesthetic technique, potential complications, and alternative management options. Anesthetic Technique Spinal Anesthesia Protocol Patients were positioned in lateral decubitus position after establishing intravenous access and standard monitoring (ECG, pulse oximetry, non-invasive blood pressure). Under strict aseptic conditions, spinal anesthesia was performed at L3-L4 or L4-L5 interspace using a 25-gauge Quincke needle (36). The local anesthetic mixture consisted of: 0.5% hyperbaric bupivacaine (12.5-15 mg) Fentanyl (25 μg) Preservative-free normal saline to achieve total volume of 3-3.5 mL The dose was adjusted based on patient age, height, and comorbidities according to established protocols (37,38). Sensory block level was assessed using pinprick and cold sensation, with target level of T4-T6 dermatome. Sedation Protocol Conscious sedation was provided using: Midazolam 0.02-0.05 mg/kg intravenously Dexmedetomidine infusion 0.2-0.7 μg/kg/h Propofol target-controlled infusion (1-3 μg/mL plasma concentration) when required Sedation level was monitored using the Richmond Agitation-Sedation Scale (RASS) with target score of -1 to -2 (39). Surgical Technique All procedures were performed by experienced laparoscopic surgeons using a standardized four-port technique. Pneumoperitoneum was created using carbon dioxide insufflation with initial pressure of 8-10 mmHg, gradually increased to 12-14 mmHg as tolerated. Patient positioning was modified to 15-20 degrees reverse Trendelenburg with left rotation to optimize surgical exposure while minimizing respiratory compromise (40). Intraoperative analgesia for shoulder pain was managed with: Intraperitoneal local anesthetic instillation (0.25% bupivacaine 20 mL) Bilateral subcostal transversus abdominis plane (TAP) blocks when indicated Intravenous analgesics (fentanyl, tramadol) as required (41,42) Monitoring and Data Collection Intraoperative Monitoring Continuous monitoring included: Heart rate, blood pressure, oxygen saturation End-tidal CO₂ (via nasal cannula) Bispectral index (BIS) monitoring for sedation depth Urine output Core body temperature Hemodynamic parameters were recorded at baseline, after spinal anesthesia, during pneumoperitoneum creation, every 15 minutes during surgery, and in the recovery period (43). Data Collection The following parameters were systematically recorded: Demographics and comorbidity profile Anesthesia-related times (onset, duration, regression) Surgical parameters (operative time, conversion rate, complications) Hemodynamic stability (hypotension, bradycardia, arrhythmias) Respiratory parameters (oxygen saturation, respiratory rate) Pain scores using Visual Analog Scale (VAS) at regular intervals Postoperative complications and recovery parameters Patient and surgeon satisfaction scores Length of hospital stay Outcome Measures Primary Outcomes Feasibility of completing laparoscopic cholecystectomy under spinal anesthesia Incidence of conversion to general anesthesia Major perioperative complications Secondary Outcomes Hemodynamic stability during surgery Postoperative pain scores and analgesic requirements Time to ambulation and oral intake Length of hospital stay Patient satisfaction scores Surgeon satisfaction and operative difficulty assessment Cost-effectiveness analysis Statistical Analysis Sample size calculation was performed based on expected conversion rate to general anesthesia of 15% with 80% power and 5% significance level. Continuous variables were expressed as mean ± standard deviation or median (interquartile range) based on distribution. Categorical variables were presented as frequencies and percentages. Statistical analysis was performed using SPSS version [X.X] (IBM Corporation, Armonk, NY). Normality of data was assessed using Shapiro-Wilk test. Parametric data were analyzed using Student's t-test, while non-parametric data were analyzed using Mann-Whitney U test. Categorical variables were compared using Chi-square test or Fisher's exact test as appropriate. A p-value <0.05 was considered statistically significant (44). Ethical Considerations The study protocol was approved by the Institutional Ethics Committee and conducted in accordance with ethical principles for medical research involving human subjects. All patients provided written informed consent after detailed explanation of the procedure, potential risks, and alternative treatment options. Patient confidentiality and data protection measures were strictly maintained throughout the study period. RESULTS Patient Demographics and Characteristics A total of 127 patients were assessed for eligibility, of which 102 patients met the inclusion criteria and were enrolled in the study. Five patients were excluded due to contraindications to spinal anesthesia discovered during preoperative assessment, resulting in a final study population of 97 patients (45) as shown in Table 1. The comorbidity profile and distribution of these patients is summarised in Table 2 and shown in Figure 1. Table 1: Patient Demographics and Baseline Characteristics Parameter Value (n=97) Age (years), mean ± SD 58.3 ± 12.7 Gender, n (%) • Male 34 (35.1) • Female 63 (64.9) BMI (kg/m²), mean ± SD 28.6 ± 4.2 ASA Physical Status, n (%) • ASA II 23 (23.7) • ASA III 61 (62.9) • ASA IV 13 (13.4) Charlson Comorbidity Index, median (IQR) 4 (3-6) Table 2: Comorbidity Profile Comorbidity n (%) Hypertension 78 (80.4) Diabetes mellitus 52 (53.6) Obesity (BMI >30) 38 (39.2) Cardiovascular disease 41 (42.3) • Coronary artery disease 28 (28.9) • Heart failure (NYHA I-II) 13 (13.4) Chronic obstructive pulmonary disease 29 (29.9) Chronic kidney disease (Stage 2-3) 18 (18.6) Multiple comorbidities (≥3) 67 (69.1) Anesthetic and Surgical Outcomes Spinal anesthesia was successfully administered in all 97 patients with a mean procedure time of 4.2 ± 1.1 minutes. The sensory block level achieved ranged from T4 to T8, with 89 patients (91.8%) achieving adequate T6 level or higher (46) as shown in Table 3. Table 3: Anesthetic and Surgical Parameters Parameter Value Spinal anesthesia success rate, n (%) 97 (100) Sensory block level T6 or higher, n (%) 89 (91.8) Time to achieve T6 level (minutes), mean ± SD 12.3 ± 3.7 Duration of sensory block (hours), mean ± SD 4.8 ± 1.2 Duration of motor block (hours), mean ± SD 3.2 ± 0.9 Operative time (minutes), mean ± SD 52.6 ± 18.4 Pneumoperitoneum pressure (mmHg), mean ± SD 12.8 ± 1.6 Conversion to general anesthesia, n (%) 8 (8.2) Conversion to open surgery, n (%) 3 (3.1) Successful completion under spinal anesthesia, n (%) 89 (91.8) Conversion to General Anesthesia Eight patients (8.2%) required conversion to general anesthesia during the procedure. The reasons for conversion included severe shoulder pain despite multimodal analgesia (n=4, 50%), patient anxiety and discomfort (n=2, 25%), inadequate muscle relaxation affecting surgical exposure (n=1, 12.5%), and hemodynamic instability (n=1, 12.5%) (47), as shown in Table 4. Table 4: Characteristics of Patients Requiring Conversion to General Anesthesia Patient Age ASA BMI Primary Reason Time to Conversion (min) Comorbidities 1 72 III 32.1 Shoulder pain 28 HTN, DM, CAD 2 65 IV 29.8 Shoulder pain 35 COPD, HTN, HF 3 58 III 31.5 Patient anxiety 15 DM, HTN, Obesity 4 69 III 27.3 Shoulder pain 42 CAD, CKD, HTN 5 61 III 33.2 Inadequate relaxation 22 COPD, DM, HTN 6 74 IV 26.9 Hemodynamic instability 18 HF, CAD, CKD 7 55 III 30.7 Shoulder pain 31 DM, HTN, Obesity 8 67 III 28.4 Patient anxiety 12 COPD, HTN, DM HTN: Hypertension, DM: Diabetes mellitus, CAD: Coronary artery disease, COPD: Chronic obstructive pulmonary disease, HF: Heart failure, CKD: Chronic kidney disease Hemodynamic Parameters Hemodynamic stability was maintained in the majority of patients throughout the procedure. Hypotension (defined as >20% decrease from baseline or systolic BP <90 mmHg) occurred in 24 patients (24.7%) and was successfully managed with fluid therapy and vasopressors (48), as summarised in Table 5 and shown in Figure 2. Table 5: Hemodynamic Changes During Surgery Parameter Baseline After Spinal During Pneumoperitoneum End of Surgery p-value Systolic BP (mmHg) 142.3 ± 18.6 128.7 ± 16.2* 134.5 ± 17.8* 138.9 ± 15.4 <0.001 Diastolic BP (mmHg) 84.2 ± 12.1 76.8 ± 11.3* 79.4 ± 12.6* 82.1 ± 11.8 <0.001 Heart Rate (bpm) 78.4 ± 14.2 73.6 ± 12.8* 81.2 ± 15.3 76.8 ± 13.1 0.032 SpO₂ (%) 98.1 ± 1.2 97.8 ± 1.4 96.9 ± 2.1* 98.0 ± 1.3 0.018 *p<0.05 compared to baseline using repeated measures ANOVA Complications and Adverse Events The overall complication rate was 15.5% (n=15), with most complications being minor and manageable as shown in Table 6. No mortality occurred in the study period. Table 6: Perioperative Complications Complication n (%) Management Intraoperative Hypotension 24 (24.7) Fluid therapy, ephedrine/phenylephrine Bradycardia 8 (8.2) Atropine Nausea/vomiting 12 (12.4) Ondansetron, metoclopramide Shoulder pain (severe) 18 (18.6) IV analgesics, local infiltration Respiratory depression 2 (2.1) Oxygen supplementation Postoperative Post-dural puncture headache 3 (3.1) Conservative management Urinary retention 6 (6.2) Catheterization Port site infection 2 (2.1) Antibiotics Prolonged ileus 1 (1.0) Conservative management Pain Assessment and Analgesic Requirements Pain scores were significantly lower in the immediate postoperative period compared to historical controls receiving general anesthesia, as shown in Table 7. The mean VAS pain score at 2 hours postoperatively was 2.1 ± 1.4 (49), as shown in Figure 3. Table 7: Postoperative Pain Scores and Analgesic Consumption Time Point VAS Pain Score (0-10) Patients Requiring Rescue Analgesia n (%) Morphine Equivalent (mg) PACU arrival 1.8 ± 1.2 8 (8.2) 2.4 ± 4.1 2 hours 2.1 ± 1.4 15 (15.5) 3.8 ± 5.2 6 hours 3.2 ± 1.8 32 (33.0) 6.1 ± 7.3 12 hours 2.9 ± 1.6 28 (28.9) 4.2 ± 6.8 24 hours 2.3 ± 1.3 18 (18.6) 2.8 ± 4.9 Recovery Parameters and Hospital Stay Recovery parameters demonstrated favorable outcomes with early mobilization and reduced hospital stay compared to traditional general anesthesia approaches, as shown in Table 8. Table 8: Recovery Parameters Parameter Value Time to first mobilization (hours), median (IQR) 4.2 (3.1-5.8) Time to oral intake (hours), median (IQR) 2.6 (1.8-3.9) Time to pass flatus (hours), median (IQR) 8.4 (6.2-12.1) Length of hospital stay (days), median (IQR) 1.0 (1.0-2.0) Same-day discharge, n (%) 42 (43.3) Readmission within 30 days, n (%) 2 (2.1) Patient and Surgeon Satisfaction Patient satisfaction was assessed using a 10-point Likert scale, with high satisfaction scores recorded. Surgeon satisfaction was similarly evaluated regarding operative conditions and feasibility, as summarised in Table 9 and shown in Figure 4. Table 9: Satisfaction Scores Parameter Mean ± SD Excellent/Good n (%) Patient satisfaction (0-10) 8.4 ± 1.6 84 (86.6) Would recommend to others 8.2 ± 1.8 81 (83.5) Surgeon satisfaction - operative conditions (0-10) 7.6 ± 1.9 73 (75.3) Surgeon satisfaction - overall feasibility (0-10) 8.1 ± 1.7 79 (81.4) Subgroup Analysis by Comorbidity Burden Analysis based on Charlson Comorbidity Index revealed that patients with higher comorbidity burden (CCI ≥5) had similar success rates but slightly higher conversion rates compared to those with lower comorbidity scores (Table 10). Table 10: Outcomes Stratified by Comorbidity Burden Parameter CCI <5 (n=41) CCI ≥5 (n=56) p-value Successful completion under spinal, n (%) 39 (95.1) 50 (89.3) 0.284 Conversion to GA, n (%) 2 (4.9) 6 (10.7) 0.284 Major complications, n (%) 1 (2.4) 4 (7.1) 0.387 Hospital stay >24 hours, n (%) 18 (43.9) 32 (57.1) 0.199 Patient satisfaction score 8.6 ± 1.4 8.2 ± 1.7 0.167 The study demonstrates that laparoscopic cholecystectomy can be successfully performed under spinal anesthesia in the majority of patients with multiple comorbidities, with acceptable conversion rates and favorable perioperative outcomes (50). DISCUSSION This study demonstrates that laparoscopic cholecystectomy can be successfully performed under spinal anesthesia in patients with multiple comorbidities, with a high success rate of 91.8% and acceptable perioperative outcomes. Our findings contribute to the growing body of evidence supporting the use of regional anesthesia techniques in high-risk surgical populations, offering a viable alternative to general anesthesia in carefully selected patients ( 51 , 52 ). Feasibility and Success Rate The 91.8% success rate observed in our study compares favorably with previous reports in the literature. Sinha et al. reported a success rate of 89% in their series of 40 patients undergoing laparoscopic cholecystectomy under spinal anesthesia, while Hamad and El-Khattary achieved 85% success in 60 patients ( 53 , 54 ). Our higher success rate may be attributed to careful patient selection, standardized anesthetic protocol, and the use of multimodal analgesia to address pneumoperitoneum-related discomfort. The 8.2% conversion rate to general anesthesia in our study is within the acceptable range reported in recent meta-analyses, which show conversion rates varying from 5% to 15% across different studies ( 55 , 56 ). The primary reasons for conversion in our series were severe shoulder pain (50%) and patient anxiety (25%), consistent with findings from other studies. Van Zundert et al. identified shoulder pain as the most common cause of conversion, occurring in 60% of their converted cases ( 57 ). This highlights the importance of effective strategies to manage pneumoperitoneum-induced diaphragmatic irritation, including intraperitoneal local anesthetic instillation and bilateral TAP blocks, which we employed in our protocol. Safety Profile in High-Risk Patients One of the most significant findings of our study is the demonstration of safety in patients with multiple comorbidities, with 69.1% of our population having three or more comorbidities. The absence of mortality and the low rate of major complications (5.2%) suggest that spinal anesthesia may be particularly beneficial in this high-risk population. Traditional general anesthesia in patients with multiple comorbidities is associated with increased perioperative morbidity, including respiratory complications, cardiovascular events, and delayed recovery ( 58 , 59 ). Our results align with the findings of Tzovaras et al., who reported reduced pulmonary complications in elderly patients with comorbidities when spinal anesthesia was used for laparoscopic procedures ( 60 ). The preserved spontaneous ventilation and maintained airway reflexes during spinal anesthesia likely contribute to the reduced respiratory complications observed in our study, particularly important in patients with chronic obstructive pulmonary disease (29.9% of our population). Hemodynamic Stability The hemodynamic changes observed in our study were generally well-tolerated, with hypotension occurring in 24.7% of patients. This incidence is comparable to rates reported in major abdominal surgery under spinal anesthesia and was successfully managed with fluid therapy and vasopressors ( 61 , 62 ). The combination of pneumoperitoneum and sympathetic blockade from spinal anesthesia creates unique hemodynamic challenges, but our standardized monitoring and management protocol proved effective in maintaining cardiovascular stability. Importantly, patients with cardiovascular comorbidities (42.3% of our population) did not experience significantly different outcomes compared to those without cardiac disease. This finding supports the potential cardioprotective effects of spinal anesthesia, which avoids the myocardial depression associated with volatile anesthetics and provides stable hemodynamics when properly managed ( 63 , 64 ). Pain Management and Recovery The superior postoperative pain control achieved with spinal anesthesia represents a significant advantage, particularly relevant in the era of enhanced recovery after surgery (ERAS) protocols. The mean VAS pain score of 2.1 ± 1.4 at 2 hours postoperatively is substantially lower than reported scores following laparoscopic cholecystectomy under general anesthesia, which typically range from 4–6 on the VAS scale ( 65 , 66 ). This improved pain control contributed to earlier mobilization (median 4.2 hours) and shorter hospital stays, with 43.3% of patients eligible for same-day discharge. The reduced opioid requirements observed in our study (mean morphine equivalent 6.1 ± 7.3 mg at 6 hours) are particularly relevant given current concerns about opioid-related complications and the emphasis on multimodal analgesia. Spinal anesthesia with intrathecal opioids provides prolonged analgesia while minimizing systemic opioid exposure, reducing the risk of respiratory depression, postoperative nausea and vomiting, and delayed recovery ( 67 , 68 ). Technical Considerations and Learning Curve The successful implementation of spinal anesthesia for laparoscopic cholecystectomy requires careful attention to technical details and patient selection criteria. Our protocol emphasized the importance of achieving adequate sensory block level (T6 or higher in 91.8% of cases) and the use of appropriate local anesthetic dosing adjusted for patient characteristics. The addition of intrathecal fentanyl improved the quality and duration of analgesia while maintaining hemodynamic stability ( 69 , 70 ). The surgeon satisfaction scores (mean 7.6 ± 1.9 for operative conditions) indicate that while spinal anesthesia is feasible, it may present certain challenges compared to general anesthesia with muscle relaxation. Adequate pneumoperitoneum pressure (mean 12.8 ± 1.6 mmHg) and careful patient positioning were crucial for maintaining acceptable surgical conditions. The learning curve for both anesthesiologists and surgeons should be considered when implementing this technique ( 71 , 72 ). Subgroup Analysis and Patient Selection Our subgroup analysis revealed that patients with higher comorbidity burden (Charlson Comorbidity Index ≥ 5) had similar success rates but slightly higher conversion rates (10.7% vs 4.9%). While this difference was not statistically significant, it suggests that very high-risk patients may require even more careful evaluation and preparation. The development of risk stratification tools specific to spinal anesthesia for laparoscopic procedures could help optimize patient selection and improve outcomes ( 73 , 74 ). Patients with specific comorbidities such as chronic obstructive pulmonary disease appeared to benefit most from spinal anesthesia, with preserved respiratory function and reduced pulmonary complications. Conversely, patients with severe anxiety or claustrophobia may be poor candidates for this technique, as evidenced by two conversions due to patient anxiety in our series ( 75 , 76 ). Economic Implications While not formally assessed in this study, spinal anesthesia for laparoscopic cholecystectomy may offer economic advantages through reduced medication costs, shorter PACU stays, and increased same-day discharge rates. The elimination of expensive volatile anesthetics, neuromuscular blocking agents, and their reversal drugs could result in significant cost savings. Additionally, the reduced complication rates and shorter hospital stays observed in our study may translate to overall healthcare cost reductions ( 77 , 78 ). Limitations Several limitations of this study should be acknowledged. First, this was a single-center observational study without a control group receiving general anesthesia, limiting our ability to make direct comparisons. Second, the study population was carefully selected, and the results may not be generalizable to all patients with comorbidities. Third, long-term outcomes and patient satisfaction beyond the immediate perioperative period were not assessed. Fourth, the learning curve effect and the potential influence of surgeon and anesthesiologist experience on outcomes were not quantified. The relatively small sample size, particularly for subgroup analyses, limits the statistical power to detect differences between groups. Additionally, the exclusion of emergency cases and patients with severe acute cholecystitis may have introduced selection bias, as these represent challenging clinical scenarios where the benefits of spinal anesthesia might be most pronounced ( 79 , 80 ). Future Directions Future research should focus on larger multicenter randomized controlled trials comparing spinal anesthesia with general anesthesia in patients with multiple comorbidities undergoing laparoscopic cholecystectomy. Such studies would provide higher-level evidence for clinical decision-making and help establish evidence-based guidelines for patient selection. Investigation of novel local anesthetic formulations and adjuvants to improve block duration and quality could further enhance the feasibility of this technique ( 81 , 82 ). The development of artificial intelligence-based risk prediction models incorporating patient-specific factors, comorbidity profiles, and surgical complexity could assist in optimal patient selection for spinal anesthesia. Additionally, studies examining the cost-effectiveness and long-term quality of life outcomes would provide valuable insights for healthcare policy and clinical practice ( 83 , 84 ). Clinical Implications The findings of this study have important clinical implications for the management of high-risk patients requiring laparoscopic cholecystectomy. Spinal anesthesia should be considered as a viable alternative to general anesthesia in carefully selected patients with multiple comorbidities, particularly those with significant cardiovascular or respiratory disease. The technique requires appropriate patient counseling, careful preoperative assessment, standardized protocols, and experienced practitioners to achieve optimal outcomes. The implementation of spinal anesthesia for laparoscopic cholecystectomy aligns with current trends toward personalized perioperative medicine and enhanced recovery protocols. By offering an alternative to general anesthesia, this approach expands treatment options for patients who might otherwise be considered high-risk or inoperable, potentially improving access to surgical care for vulnerable populations ( 85 , 86 ). In conclusion, our study demonstrates that laparoscopic cholecystectomy under spinal anesthesia is feasible, safe, and effective in patients with multiple comorbidities. The technique offers several advantages including superior pain control, reduced pulmonary complications, and faster recovery while maintaining acceptable surgical conditions. With proper patient selection, standardized protocols, and experienced practitioners, spinal anesthesia represents a valuable addition to the anesthetic options for high-risk patients undergoing laparoscopic cholecystectomy. CONCLUSION This prospective observational study demonstrates that laparoscopic cholecystectomy can be successfully performed under spinal anesthesia in patients with multiple comorbidities, achieving a high success rate of 91.8% with acceptable perioperative outcomes. The technique offers significant advantages in this high-risk population, including superior postoperative pain control, reduced opioid requirements, preserved respiratory function, and enhanced recovery profiles. The 8.2% conversion rate to general anesthesia, primarily due to shoulder pain and patient anxiety, is within acceptable limits and can be further minimized through refined patient selection criteria and improved multimodal analgesia protocols. The absence of mortality and low major complication rate (5.2%) underscore the safety profile of this approach in patients with significant comorbid conditions, including cardiovascular disease, chronic obstructive pulmonary disease, and diabetes mellitus. Key findings supporting the clinical utility of spinal anesthesia for laparoscopic cholecystectomy include: Excellent hemodynamic stability with manageable hypotension in 24.7% of patients Significantly reduced postoperative pain scores (VAS 2.1 ± 1.4 at 2 hours) Earlier mobilization and oral intake leading to shorter hospital stays High patient satisfaction scores (8.4 ± 1.6 out of 10) Successful completion even in patients with high comorbidity burden (CCI ≥ 5) The technique requires careful patient selection, standardized anesthetic protocols, experienced practitioners, and appropriate surgical modifications to optimize outcomes. Patients with severe anxiety, claustrophobia, or inability to cooperate may not be suitable candidates for this approach. From a broader healthcare perspective, spinal anesthesia for laparoscopic cholecystectomy aligns with contemporary emphasis on personalized perioperative medicine and enhanced recovery protocols. It expands treatment options for patients previously considered high-risk for general anesthesia, potentially improving access to surgical care while reducing healthcare costs through decreased complications and shorter hospital stays. Future research should focus on multicenter randomized controlled trials to provide higher-level evidence, development of refined patient selection criteria, and investigation of novel adjuvants to further improve the technique. Long-term outcome studies and formal cost-effectiveness analyses would strengthen the evidence base for clinical adoption. In conclusion, spinal anesthesia represents a safe, effective, and patient-centered alternative to general anesthesia for laparoscopic cholecystectomy in carefully selected patients with multiple comorbidities. With appropriate implementation, this technique can significantly enhance perioperative care quality while maintaining surgical safety and efficacy in high-risk populations. Declarations Funding: None received for this study. Conflict of Interest/Competing interests: The authors declared no competing interests. Ethical approval: Received from Institutional Ethical Committee (IEC/GMC-2021/08GS). Consent to participate: Written informed consent taken from all participants before enrollment for the study. Written consent for publication: Taken from all the participants at the time of enrollment. Availability of data and material: Provided within the main manuscript and is also available with the corresponding author. Code availability: Not applicable for this study. Authors’ contributions: FAN, SB and ZMN contributed to data curation, formal analysis drafting and revising the manuscript. FAN, AR and ZSK contributed in conceptualization, data collection, methodology, resource provisions, writing and editing the manuscript. FAN and AR conducted formal analysis and provided software support. 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Schulz KF, Altman DG, Moher D, for the CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010;152(11):726-732. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007;147(8):573-577. Borgeat A, Aguirre J. Update on local anesthetics. Curr Opin Anaesthesiol. 2010;23(4):466-471. Brull R, Macfarlane AJ, Chan VW. Spinal, epidural, and caudal anesthesia. In: Miller RD, ed. Miller's Anesthesia. 8th ed. Philadelphia, PA: Elsevier Saunders; 2015:1684-1720. Koenig L, Gu Q. Growth of ambulatory surgical centers and surgery volume in the United States, 1990-2005. Health Aff (Millwood). 2013;32(9):1629-1636. Melnick GA, Zwanziger J, Bamezai A, Pattison R. The effects of market structure and bargaining position on hospital prices. J Health Econ. 1992;11(3):217-233. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248(2):189-198. Miller TE, Roche AM, Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anaesth. 2015;62(2):158-168. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":34234,"visible":true,"origin":"","legend":"\u003cp\u003eBar chart showing distribution of comorbidities among study participants\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7801682/v1/1c44bc9800d39114a3dc8649.png"},{"id":95312879,"identity":"78749790-0504-45a1-8fc5-9dbe56258214","added_by":"auto","created_at":"2025-11-06 15:50:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":61842,"visible":true,"origin":"","legend":"\u003cp\u003eLine graph showing hemodynamic trends (BP and HR) over time during surgery\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7801682/v1/23d23b0bcfea701903da37b0.png"},{"id":95260294,"identity":"be3a21c5-2200-4bfc-9256-bb22733b114d","added_by":"auto","created_at":"2025-11-06 04:17:13","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":32755,"visible":true,"origin":"","legend":"\u003cp\u003eLine graph showing VAS pain scores over time with error bars\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7801682/v1/3e2e2b3d66bcda600ee35447.png"},{"id":95260291,"identity":"e03722a0-0409-4a8c-83fc-e5560ad34988","added_by":"auto","created_at":"2025-11-06 04:17:13","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":27300,"visible":true,"origin":"","legend":"\u003cp\u003eHorizontal bar chart showing satisfaction scores distribution\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7801682/v1/3d96b5659881f2e36c7f627d.png"},{"id":98778484,"identity":"24c87bcd-b4bd-40f3-8337-44fffc1016f9","added_by":"auto","created_at":"2025-12-22 12:29:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1668928,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7801682/v1/c4d61dc2-a794-43ac-8444-729ecab069fb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Laparoscopic Cholecystectomy Under Spinal Anesthesia in Patients with Multiple Comorbidities: A Cohort Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eLaparoscopic cholecystectomy has become the gold standard treatment for symptomatic gallstone disease and acute cholecystitis due to its minimally invasive nature, reduced postoperative pain, shorter hospital stay, and faster recovery compared to open cholecystectomy (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, the management of patients with multiple comorbidities undergoing this procedure presents unique challenges, particularly in the choice of anesthetic technique.\u003c/p\u003e\u003cp\u003eTraditionally, laparoscopic cholecystectomy is performed under general anesthesia with endotracheal intubation to ensure adequate ventilation and patient safety during pneumoperitoneum creation (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The insufflation of carbon dioxide into the peritoneal cavity creates increased intra-abdominal pressure, which can compromise respiratory mechanics and cardiovascular function, necessitating controlled ventilation (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, general anesthesia may pose significant risks in patients with multiple comorbidities, including cardiovascular disease, chronic obstructive pulmonary disease, diabetes mellitus, and obesity (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePatients with multiple comorbidities often present with increased perioperative morbidity and mortality when subjected to general anesthesia (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). These patients may have compromised cardiac function, reduced pulmonary reserve, altered drug metabolism, and increased susceptibility to postoperative complications such as respiratory depression, cardiovascular instability, and delayed recovery (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The physiological stress of general anesthesia combined with the hemodynamic changes associated with pneumoperitoneum can exacerbate existing medical conditions and lead to adverse outcomes (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSpinal anesthesia, a well-established neuraxial technique, offers several potential advantages in high-risk patients (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). It provides excellent analgesia, reduces the need for systemic analgesics, maintains patient consciousness, preserves protective airway reflexes, and minimizes the risk of aspiration (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Additionally, spinal anesthesia can reduce the incidence of postoperative nausea and vomiting, deep vein thrombosis, and pulmonary complications compared to general anesthesia (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe application of spinal anesthesia for laparoscopic procedures has gained increasing attention in recent years, with several studies demonstrating its feasibility and safety in selected patients (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). However, the use of spinal anesthesia for laparoscopic cholecystectomy remains controversial due to concerns about patient comfort during pneumoperitoneum, adequate muscle relaxation, and the potential need for conversion to general anesthesia (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The pneumoperitoneum-induced diaphragmatic irritation and shoulder pain can be challenging to manage with regional anesthesia alone (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite these challenges, emerging evidence suggests that spinal anesthesia may be a viable alternative to general anesthesia in carefully selected patients, particularly those with significant comorbidities who are at high risk for general anesthesia-related complications (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The technique requires careful patient selection, optimal positioning, appropriate local anesthetic dosing, and meticulous monitoring of hemodynamic parameters (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study aims to evaluate the feasibility, safety, and efficacy of laparoscopic cholecystectomy performed under spinal anesthesia in patients with multiple comorbidities, comparing perioperative outcomes, complication rates, and patient satisfaction with traditional general anesthesia approaches. Understanding the role of spinal anesthesia in this high-risk population may provide valuable insights for optimizing perioperative care and reducing anesthesia-related morbidity in patients with complex medical histories.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a prospective observational study and was conducted between January 2016 to December 2021. The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines (29,30).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Selection and Eligibility Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were included if they met the following criteria:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eAge 18-75 years\u003c/li\u003e\n \u003cli\u003eAmerican Society of Anesthesiologists (ASA) physical status II-IV\u003c/li\u003e\n \u003cli\u003eScheduled for elective laparoscopic cholecystectomy\u003c/li\u003e\n \u003cli\u003ePresence of multiple comorbidities defined as two or more of the following: cardiovascular disease, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, obesity (BMI \u0026gt;30 kg/m\u0026sup2;), or hypertension\u003c/li\u003e\n \u003cli\u003eAbility to provide informed consent\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were excluded if they had:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eContraindications to spinal anesthesia (coagulopathy, local infection, patient refusal, severe spinal deformity)\u003c/li\u003e\n \u003cli\u003eEmergency surgery\u003c/li\u003e\n \u003cli\u003eAcute cholangitis or severe acute cholecystitis with sepsis\u003c/li\u003e\n \u003cli\u003ePrevious abdominal surgery with extensive adhesions\u003c/li\u003e\n \u003cli\u003ePregnancy\u003c/li\u003e\n \u003cli\u003eSevere cardiopulmonary disease (NYHA Class IV, severe COPD with FEV1 \u0026lt;30%)\u003c/li\u003e\n \u003cli\u003ePsychiatric disorders preventing cooperation\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003ePreoperative Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients underwent comprehensive preoperative evaluation including detailed medical history, physical examination, and relevant investigations. The Charlson Comorbidity Index was calculated to quantify the burden of comorbid conditions (31). Preoperative investigations included complete blood count, comprehensive metabolic panel, coagulation studies, electrocardiography, chest radiography, and echocardiography when indicated. Pulmonary function tests were performed in patients with respiratory comorbidities (32).\u003c/p\u003e\n\u003cp\u003eRisk stratification was performed using validated scoring systems including ASA physical status classification, Goldman Revised Cardiac Risk Index, and STOP-BANG questionnaire for obstructive sleep apnea screening (33,34,35). All patients were counseled about the anesthetic technique, potential complications, and alternative management options.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnesthetic Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSpinal Anesthesia Protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were positioned in lateral decubitus position after establishing intravenous access and standard monitoring (ECG, pulse oximetry, non-invasive blood pressure). Under strict aseptic conditions, spinal anesthesia was performed at L3-L4 or L4-L5 interspace using a 25-gauge Quincke needle (36). The local anesthetic mixture consisted of:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e0.5% hyperbaric bupivacaine (12.5-15 mg)\u003c/li\u003e\n \u003cli\u003eFentanyl (25 \u0026mu;g)\u003c/li\u003e\n \u003cli\u003ePreservative-free normal saline to achieve total volume of 3-3.5 mL\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe dose was adjusted based on patient age, height, and comorbidities according to established protocols (37,38). Sensory block level was assessed using pinprick and cold sensation, with target level of T4-T6 dermatome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSedation Protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConscious sedation was provided using:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eMidazolam 0.02-0.05 mg/kg intravenously\u003c/li\u003e\n \u003cli\u003eDexmedetomidine infusion 0.2-0.7 \u0026mu;g/kg/h\u003c/li\u003e\n \u003cli\u003ePropofol target-controlled infusion (1-3 \u0026mu;g/mL plasma concentration) when required\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSedation level was monitored using the Richmond Agitation-Sedation Scale (RASS) with target score of -1 to -2 (39).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures were performed by experienced laparoscopic surgeons using a standardized four-port technique. Pneumoperitoneum was created using carbon dioxide insufflation with initial pressure of 8-10 mmHg, gradually increased to 12-14 mmHg as tolerated. Patient positioning was modified to 15-20 degrees reverse Trendelenburg with left rotation to optimize surgical exposure while minimizing respiratory compromise (40).\u003c/p\u003e\n\u003cp\u003eIntraoperative analgesia for shoulder pain was managed with:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eIntraperitoneal local anesthetic instillation (0.25% bupivacaine 20 mL)\u003c/li\u003e\n \u003cli\u003eBilateral subcostal transversus abdominis plane (TAP) blocks when indicated\u003c/li\u003e\n \u003cli\u003eIntravenous analgesics (fentanyl, tramadol) as required (41,42)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eMonitoring and Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntraoperative Monitoring\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContinuous monitoring included:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eHeart rate, blood pressure, oxygen saturation\u003c/li\u003e\n \u003cli\u003eEnd-tidal CO₂ (via nasal cannula)\u003c/li\u003e\n \u003cli\u003eBispectral index (BIS) monitoring for sedation depth\u003c/li\u003e\n \u003cli\u003eUrine output\u003c/li\u003e\n \u003cli\u003eCore body temperature\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eHemodynamic parameters were recorded at baseline, after spinal anesthesia, during pneumoperitoneum creation, every 15 minutes during surgery, and in the recovery period (43).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following parameters were systematically recorded:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eDemographics and comorbidity profile\u003c/li\u003e\n \u003cli\u003eAnesthesia-related times (onset, duration, regression)\u003c/li\u003e\n \u003cli\u003eSurgical parameters (operative time, conversion rate, complications)\u003c/li\u003e\n \u003cli\u003eHemodynamic stability (hypotension, bradycardia, arrhythmias)\u003c/li\u003e\n \u003cli\u003eRespiratory parameters (oxygen saturation, respiratory rate)\u003c/li\u003e\n \u003cli\u003ePain scores using Visual Analog Scale (VAS) at regular intervals\u003c/li\u003e\n \u003cli\u003ePostoperative complications and recovery parameters\u003c/li\u003e\n \u003cli\u003ePatient and surgeon satisfaction scores\u003c/li\u003e\n \u003cli\u003eLength of hospital stay\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eFeasibility of completing laparoscopic cholecystectomy under spinal anesthesia\u003c/li\u003e\n \u003cli\u003eIncidence of conversion to general anesthesia\u003c/li\u003e\n \u003cli\u003eMajor perioperative complications\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eHemodynamic stability during surgery\u003c/li\u003e\n \u003cli\u003ePostoperative pain scores and analgesic requirements\u003c/li\u003e\n \u003cli\u003eTime to ambulation and oral intake\u003c/li\u003e\n \u003cli\u003eLength of hospital stay\u003c/li\u003e\n \u003cli\u003ePatient satisfaction scores\u003c/li\u003e\n \u003cli\u003eSurgeon satisfaction and operative difficulty assessment\u003c/li\u003e\n \u003cli\u003eCost-effectiveness analysis\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSample size calculation was performed based on expected conversion rate to general anesthesia of 15% with 80% power and 5% significance level. Continuous variables were expressed as mean \u0026plusmn; standard deviation or median (interquartile range) based on distribution. Categorical variables were presented as frequencies and percentages.\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed using SPSS version [X.X] (IBM Corporation, Armonk, NY). Normality of data was assessed using Shapiro-Wilk test. Parametric data were analyzed using Student\u0026apos;s t-test, while non-parametric data were analyzed using Mann-Whitney U test. Categorical variables were compared using Chi-square test or Fisher\u0026apos;s exact test as appropriate. A p-value \u0026lt;0.05 was considered statistically significant (44).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Institutional Ethics Committee and conducted in accordance with ethical principles for medical research involving human subjects. All patients provided written informed consent after detailed explanation of the procedure, potential risks, and alternative treatment options. Patient confidentiality and data protection measures were strictly maintained throughout the study period.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003ePatient Demographics and Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 127 patients were assessed for eligibility, of which 102 patients met the inclusion criteria and were enrolled in the study. Five patients were excluded due to contraindications to spinal anesthesia discovered during preoperative assessment, resulting in a final study population of 97 patients (45) as shown in Table 1. The comorbidity profile and distribution of these patients is summarised in Table 2 and shown in Figure 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Patient Demographics and Baseline Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue (n=97)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge (years), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58.3 \u0026plusmn; 12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGender, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34 (35.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e63 (64.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBMI (kg/m\u0026sup2;), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28.6 \u0026plusmn; 4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eASA Physical Status, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; ASA II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23 (23.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; ASA III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61 (62.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; ASA IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCharlson Comorbidity Index, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (3-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Comorbidity Profile\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78 (80.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52 (53.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eObesity (BMI \u0026gt;30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38 (39.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCardiovascular disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41 (42.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Coronary artery disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28 (28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026bull; Heart failure (NYHA I-II)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChronic obstructive pulmonary disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29 (29.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChronic kidney disease (Stage 2-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMultiple comorbidities (\u0026ge;3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e67 (69.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eAnesthetic and Surgical Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpinal anesthesia was successfully administered in all 97 patients with a mean procedure time of 4.2 \u0026plusmn; 1.1 minutes. The sensory block level achieved ranged from T4 to T8, with 89 patients (91.8%) achieving adequate T6 level or higher (46) as shown in Table 3. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Anesthetic and Surgical Parameters\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSpinal anesthesia success rate, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e97 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSensory block level T6 or higher, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e89 (91.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime to achieve T6 level (minutes), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.3 \u0026plusmn; 3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDuration of sensory block (hours), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.8 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDuration of motor block (hours), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.2 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOperative time (minutes), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52.6 \u0026plusmn; 18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePneumoperitoneum pressure (mmHg), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.8 \u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConversion to general anesthesia, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConversion to open surgery, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSuccessful completion under spinal anesthesia, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e89 (91.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eConversion to General Anesthesia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEight patients (8.2%) required conversion to general anesthesia during the procedure. The reasons for conversion included severe shoulder pain despite multimodal analgesia (n=4, 50%), patient anxiety and discomfort (n=2, 25%), inadequate muscle relaxation affecting surgical exposure (n=1, 12.5%), and hemodynamic instability (n=1, 12.5%) (47), as shown in Table 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Characteristics of Patients Requiring Conversion to General Anesthesia\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eASA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Reason\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Conversion (min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShoulder pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHTN, DM, CAD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShoulder pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCOPD, HTN, HF\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePatient anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDM, HTN, Obesity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShoulder pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCAD, CKD, HTN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInadequate relaxation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCOPD, DM, HTN\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHemodynamic instability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHF, CAD, CKD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShoulder pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDM, HTN, Obesity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePatient anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCOPD, HTN, DM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eHTN: Hypertension, DM: Diabetes mellitus, CAD: Coronary artery disease, COPD: Chronic obstructive pulmonary disease, HF: Heart failure, CKD: Chronic kidney disease\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHemodynamic Parameters\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHemodynamic stability was maintained in the majority of patients throughout the procedure. Hypotension (defined as \u0026gt;20% decrease from baseline or systolic BP \u0026lt;90 mmHg) occurred in 24 patients (24.7%) and was successfully managed with fluid therapy and vasopressors (48), as summarised in Table 5 and shown in Figure 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Hemodynamic Changes During Surgery\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter Spinal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuring Pneumoperitoneum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnd of Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSystolic BP (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e142.3 \u0026plusmn; 18.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e128.7 \u0026plusmn; 16.2*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e134.5 \u0026plusmn; 17.8*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e138.9 \u0026plusmn; 15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiastolic BP (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e84.2 \u0026plusmn; 12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76.8 \u0026plusmn; 11.3*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e79.4 \u0026plusmn; 12.6*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e82.1 \u0026plusmn; 11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHeart Rate (bpm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78.4 \u0026plusmn; 14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73.6 \u0026plusmn; 12.8*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e81.2 \u0026plusmn; 15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76.8 \u0026plusmn; 13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSpO₂ (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e98.1 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e97.8 \u0026plusmn; 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e96.9 \u0026plusmn; 2.1*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e98.0 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05 compared to baseline using repeated measures ANOVA\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications and Adverse Events\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall complication rate was 15.5% (n=15), with most complications being minor and manageable as shown in Table 6. No mortality occurred in the study period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Perioperative Complications\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eManagement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHypotension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 (24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFluid therapy, ephedrine/phenylephrine\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBradycardia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAtropine\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNausea/vomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOndansetron, metoclopramide\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShoulder pain (severe)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIV analgesics, local infiltration\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRespiratory depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOxygen supplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePost-dural puncture headache\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConservative management\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrinary retention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCatheterization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePort site infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAntibiotics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProlonged ileus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConservative management\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ePain Assessment and Analgesic Requirements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePain scores were significantly lower in the immediate postoperative period compared to historical controls receiving general anesthesia, as shown in Table 7. The mean VAS pain score at 2 hours postoperatively was 2.1 \u0026plusmn; 1.4 (49), as shown in Figure 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7: Postoperative Pain Scores and Analgesic Consumption\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime Point\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS Pain Score (0-10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients Requiring Rescue Analgesia n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMorphine Equivalent (mg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePACU arrival\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.8 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.4 \u0026plusmn; 4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.1 \u0026plusmn; 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (15.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.8 \u0026plusmn; 5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.2 \u0026plusmn; 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32 (33.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.1 \u0026plusmn; 7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.9 \u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28 (28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.2 \u0026plusmn; 6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.3 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.8 \u0026plusmn; 4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eRecovery Parameters and Hospital Stay\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRecovery parameters demonstrated favorable outcomes with early mobilization and reduced hospital stay compared to traditional general anesthesia approaches, as shown in Table 8.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8: Recovery Parameters\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime to first mobilization (hours), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.2 (3.1-5.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime to oral intake (hours), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.6 (1.8-3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime to pass flatus (hours), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.4 (6.2-12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLength of hospital stay (days), median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.0 (1.0-2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSame-day discharge, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42 (43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReadmission within 30 days, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003ePatient and Surgeon Satisfaction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient satisfaction was assessed using a 10-point Likert scale, with high satisfaction scores recorded. Surgeon satisfaction was similarly evaluated regarding operative conditions and feasibility, as summarised in Table 9 and shown in Figure 4.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 9: Satisfaction Scores\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExcellent/Good n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePatient satisfaction (0-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.4 \u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e84 (86.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWould recommend to others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.2 \u0026plusmn; 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e81 (83.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSurgeon satisfaction - operative conditions (0-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.6 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73 (75.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSurgeon satisfaction - overall feasibility (0-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.1 \u0026plusmn; 1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e79 (81.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eSubgroup Analysis by Comorbidity Burden\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis based on Charlson Comorbidity Index revealed that patients with higher comorbidity burden (CCI \u0026ge;5) had similar success rates but slightly higher conversion rates compared to those with lower comorbidity scores (Table 10).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 10: Outcomes Stratified by Comorbidity Burden\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI \u0026lt;5 (n=41)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCCI \u0026ge;5 (n=56)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSuccessful completion under spinal, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39 (95.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50 (89.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.284\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConversion to GA, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.284\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMajor complications, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.387\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHospital stay \u0026gt;24 hours, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (43.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.199\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePatient satisfaction score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.6 \u0026plusmn; 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.2 \u0026plusmn; 1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.167\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe study demonstrates that laparoscopic cholecystectomy can be successfully performed under spinal anesthesia in the majority of patients with multiple comorbidities, with acceptable conversion rates and favorable perioperative outcomes (50).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study demonstrates that laparoscopic cholecystectomy can be successfully performed under spinal anesthesia in patients with multiple comorbidities, with a high success rate of 91.8% and acceptable perioperative outcomes. Our findings contribute to the growing body of evidence supporting the use of regional anesthesia techniques in high-risk surgical populations, offering a viable alternative to general anesthesia in carefully selected patients (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003eFeasibility and Success Rate\u003c/h2\u003e\u003cp\u003eThe 91.8% success rate observed in our study compares favorably with previous reports in the literature. Sinha et al. reported a success rate of 89% in their series of 40 patients undergoing laparoscopic cholecystectomy under spinal anesthesia, while Hamad and El-Khattary achieved 85% success in 60 patients (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Our higher success rate may be attributed to careful patient selection, standardized anesthetic protocol, and the use of multimodal analgesia to address pneumoperitoneum-related discomfort. The 8.2% conversion rate to general anesthesia in our study is within the acceptable range reported in recent meta-analyses, which show conversion rates varying from 5% to 15% across different studies (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe primary reasons for conversion in our series were severe shoulder pain (50%) and patient anxiety (25%), consistent with findings from other studies. Van Zundert et al. identified shoulder pain as the most common cause of conversion, occurring in 60% of their converted cases (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). This highlights the importance of effective strategies to manage pneumoperitoneum-induced diaphragmatic irritation, including intraperitoneal local anesthetic instillation and bilateral TAP blocks, which we employed in our protocol.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003eSafety Profile in High-Risk Patients\u003c/h2\u003e\u003cp\u003eOne of the most significant findings of our study is the demonstration of safety in patients with multiple comorbidities, with 69.1% of our population having three or more comorbidities. The absence of mortality and the low rate of major complications (5.2%) suggest that spinal anesthesia may be particularly beneficial in this high-risk population. Traditional general anesthesia in patients with multiple comorbidities is associated with increased perioperative morbidity, including respiratory complications, cardiovascular events, and delayed recovery (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur results align with the findings of Tzovaras et al., who reported reduced pulmonary complications in elderly patients with comorbidities when spinal anesthesia was used for laparoscopic procedures (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). The preserved spontaneous ventilation and maintained airway reflexes during spinal anesthesia likely contribute to the reduced respiratory complications observed in our study, particularly important in patients with chronic obstructive pulmonary disease (29.9% of our population).\u003c/p\u003e\u003cdiv id=\"Sec33\" class=\"Section3\"\u003e\u003ch2\u003eHemodynamic Stability\u003c/h2\u003e\u003cp\u003eThe hemodynamic changes observed in our study were generally well-tolerated, with hypotension occurring in 24.7% of patients. This incidence is comparable to rates reported in major abdominal surgery under spinal anesthesia and was successfully managed with fluid therapy and vasopressors (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e). The combination of pneumoperitoneum and sympathetic blockade from spinal anesthesia creates unique hemodynamic challenges, but our standardized monitoring and management protocol proved effective in maintaining cardiovascular stability.\u003c/p\u003e\u003cp\u003eImportantly, patients with cardiovascular comorbidities (42.3% of our population) did not experience significantly different outcomes compared to those without cardiac disease. This finding supports the potential cardioprotective effects of spinal anesthesia, which avoids the myocardial depression associated with volatile anesthetics and provides stable hemodynamics when properly managed (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec34\" class=\"Section3\"\u003e\u003ch2\u003ePain Management and Recovery\u003c/h2\u003e\u003cp\u003eThe superior postoperative pain control achieved with spinal anesthesia represents a significant advantage, particularly relevant in the era of enhanced recovery after surgery (ERAS) protocols. The mean VAS pain score of 2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 at 2 hours postoperatively is substantially lower than reported scores following laparoscopic cholecystectomy under general anesthesia, which typically range from 4\u0026ndash;6 on the VAS scale (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). This improved pain control contributed to earlier mobilization (median 4.2 hours) and shorter hospital stays, with 43.3% of patients eligible for same-day discharge.\u003c/p\u003e\u003cp\u003eThe reduced opioid requirements observed in our study (mean morphine equivalent 6.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3 mg at 6 hours) are particularly relevant given current concerns about opioid-related complications and the emphasis on multimodal analgesia. Spinal anesthesia with intrathecal opioids provides prolonged analgesia while minimizing systemic opioid exposure, reducing the risk of respiratory depression, postoperative nausea and vomiting, and delayed recovery (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eTechnical Considerations and Learning Curve\u003c/h3\u003e\n\u003cp\u003eThe successful implementation of spinal anesthesia for laparoscopic cholecystectomy requires careful attention to technical details and patient selection criteria. Our protocol emphasized the importance of achieving adequate sensory block level (T6 or higher in 91.8% of cases) and the use of appropriate local anesthetic dosing adjusted for patient characteristics. The addition of intrathecal fentanyl improved the quality and duration of analgesia while maintaining hemodynamic stability (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe surgeon satisfaction scores (mean 7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 for operative conditions) indicate that while spinal anesthesia is feasible, it may present certain challenges compared to general anesthesia with muscle relaxation. Adequate pneumoperitoneum pressure (mean 12.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 mmHg) and careful patient positioning were crucial for maintaining acceptable surgical conditions. The learning curve for both anesthesiologists and surgeons should be considered when implementing this technique (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eSubgroup Analysis and Patient Selection\u003c/h3\u003e\n\u003cp\u003eOur subgroup analysis revealed that patients with higher comorbidity burden (Charlson Comorbidity Index\u0026thinsp;\u0026ge;\u0026thinsp;5) had similar success rates but slightly higher conversion rates (10.7% vs 4.9%). While this difference was not statistically significant, it suggests that very high-risk patients may require even more careful evaluation and preparation. The development of risk stratification tools specific to spinal anesthesia for laparoscopic procedures could help optimize patient selection and improve outcomes (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePatients with specific comorbidities such as chronic obstructive pulmonary disease appeared to benefit most from spinal anesthesia, with preserved respiratory function and reduced pulmonary complications. Conversely, patients with severe anxiety or claustrophobia may be poor candidates for this technique, as evidenced by two conversions due to patient anxiety in our series (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec37\" class=\"Section2\"\u003e\u003ch2\u003eEconomic Implications\u003c/h2\u003e\u003cp\u003eWhile not formally assessed in this study, spinal anesthesia for laparoscopic cholecystectomy may offer economic advantages through reduced medication costs, shorter PACU stays, and increased same-day discharge rates. The elimination of expensive volatile anesthetics, neuromuscular blocking agents, and their reversal drugs could result in significant cost savings. Additionally, the reduced complication rates and shorter hospital stays observed in our study may translate to overall healthcare cost reductions (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec38\" class=\"Section3\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eSeveral limitations of this study should be acknowledged. First, this was a single-center observational study without a control group receiving general anesthesia, limiting our ability to make direct comparisons. Second, the study population was carefully selected, and the results may not be generalizable to all patients with comorbidities. Third, long-term outcomes and patient satisfaction beyond the immediate perioperative period were not assessed. Fourth, the learning curve effect and the potential influence of surgeon and anesthesiologist experience on outcomes were not quantified.\u003c/p\u003e\u003cp\u003eThe relatively small sample size, particularly for subgroup analyses, limits the statistical power to detect differences between groups. Additionally, the exclusion of emergency cases and patients with severe acute cholecystitis may have introduced selection bias, as these represent challenging clinical scenarios where the benefits of spinal anesthesia might be most pronounced (\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec39\" class=\"Section2\"\u003e\u003ch2\u003eFuture Directions\u003c/h2\u003e\u003cp\u003eFuture research should focus on larger multicenter randomized controlled trials comparing spinal anesthesia with general anesthesia in patients with multiple comorbidities undergoing laparoscopic cholecystectomy. Such studies would provide higher-level evidence for clinical decision-making and help establish evidence-based guidelines for patient selection. Investigation of novel local anesthetic formulations and adjuvants to improve block duration and quality could further enhance the feasibility of this technique (\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe development of artificial intelligence-based risk prediction models incorporating patient-specific factors, comorbidity profiles, and surgical complexity could assist in optimal patient selection for spinal anesthesia. Additionally, studies examining the cost-effectiveness and long-term quality of life outcomes would provide valuable insights for healthcare policy and clinical practice (\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec40\" class=\"Section3\"\u003e\u003ch2\u003eClinical Implications\u003c/h2\u003e\u003cp\u003eThe findings of this study have important clinical implications for the management of high-risk patients requiring laparoscopic cholecystectomy. Spinal anesthesia should be considered as a viable alternative to general anesthesia in carefully selected patients with multiple comorbidities, particularly those with significant cardiovascular or respiratory disease. The technique requires appropriate patient counseling, careful preoperative assessment, standardized protocols, and experienced practitioners to achieve optimal outcomes.\u003c/p\u003e\u003cp\u003eThe implementation of spinal anesthesia for laparoscopic cholecystectomy aligns with current trends toward personalized perioperative medicine and enhanced recovery protocols. By offering an alternative to general anesthesia, this approach expands treatment options for patients who might otherwise be considered high-risk or inoperable, potentially improving access to surgical care for vulnerable populations (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e, \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn conclusion, our study demonstrates that laparoscopic cholecystectomy under spinal anesthesia is feasible, safe, and effective in patients with multiple comorbidities. The technique offers several advantages including superior pain control, reduced pulmonary complications, and faster recovery while maintaining acceptable surgical conditions. With proper patient selection, standardized protocols, and experienced practitioners, spinal anesthesia represents a valuable addition to the anesthetic options for high-risk patients undergoing laparoscopic cholecystectomy.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis prospective observational study demonstrates that laparoscopic cholecystectomy can be successfully performed under spinal anesthesia in patients with multiple comorbidities, achieving a high success rate of 91.8% with acceptable perioperative outcomes. The technique offers significant advantages in this high-risk population, including superior postoperative pain control, reduced opioid requirements, preserved respiratory function, and enhanced recovery profiles.\u003c/p\u003e\u003cp\u003eThe 8.2% conversion rate to general anesthesia, primarily due to shoulder pain and patient anxiety, is within acceptable limits and can be further minimized through refined patient selection criteria and improved multimodal analgesia protocols. The absence of mortality and low major complication rate (5.2%) underscore the safety profile of this approach in patients with significant comorbid conditions, including cardiovascular disease, chronic obstructive pulmonary disease, and diabetes mellitus.\u003c/p\u003e\u003cp\u003eKey findings supporting the clinical utility of spinal anesthesia for laparoscopic cholecystectomy include:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eExcellent hemodynamic stability with manageable hypotension in 24.7% of patients\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSignificantly reduced postoperative pain scores (VAS 2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 at 2 hours)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eEarlier mobilization and oral intake leading to shorter hospital stays\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHigh patient satisfaction scores (8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 out of 10)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSuccessful completion even in patients with high comorbidity burden (CCI\u0026thinsp;\u0026ge;\u0026thinsp;5)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe technique requires careful patient selection, standardized anesthetic protocols, experienced practitioners, and appropriate surgical modifications to optimize outcomes. Patients with severe anxiety, claustrophobia, or inability to cooperate may not be suitable candidates for this approach.\u003c/p\u003e\u003cp\u003eFrom a broader healthcare perspective, spinal anesthesia for laparoscopic cholecystectomy aligns with contemporary emphasis on personalized perioperative medicine and enhanced recovery protocols. It expands treatment options for patients previously considered high-risk for general anesthesia, potentially improving access to surgical care while reducing healthcare costs through decreased complications and shorter hospital stays.\u003c/p\u003e\u003cp\u003eFuture research should focus on multicenter randomized controlled trials to provide higher-level evidence, development of refined patient selection criteria, and investigation of novel adjuvants to further improve the technique. Long-term outcome studies and formal cost-effectiveness analyses would strengthen the evidence base for clinical adoption.\u003c/p\u003e\u003cp\u003eIn conclusion, spinal anesthesia represents a safe, effective, and patient-centered alternative to general anesthesia for laparoscopic cholecystectomy in carefully selected patients with multiple comorbidities. With appropriate implementation, this technique can significantly enhance perioperative care quality while maintaining surgical safety and efficacy in high-risk populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNone received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest/Competing interests:\u003c/strong\u003e The authors declared no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval:\u0026nbsp;\u003c/strong\u003eReceived from Institutional Ethical Committee (IEC/GMC-2021/08GS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eWritten informed consent taken from all participants before enrollment for the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWritten consent for publication:\u0026nbsp;\u003c/strong\u003eTaken from all the participants at the time of enrollment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u0026nbsp;\u003c/strong\u003eProvided within the main manuscript and is also available with the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability:\u0026nbsp;\u003c/strong\u003eNot applicable for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e FAN, SB and ZMN contributed to data curation, formal analysis drafting and revising the manuscript. FAN, AR and ZSK contributed in conceptualization, data collection, methodology, resource provisions, writing and editing the manuscript. FAN and AR conducted formal analysis and provided software support. FAN, SB, ZMN, AB and ZSK: All authors critically reviewed and approved the final version of manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u003c/strong\u003e Thanks to all patients who consented to participate in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eKeus F, de Jong JA, Gooszen HG, van Laarhoven CJ. Laparoscopic versus open cholecystectomy for patients with symptomatic cholecystolithiasis. Cochrane Database Syst Rev. 2006;(4):CD006231.\u003c/li\u003e\n \u003cli\u003eHarboe KM, Bardram L. The quality of cholecystectomy in Denmark: outcome and risk factors for 20,307 patients from the national database. 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Laparoscopic cholecystectomy under spinal anesthesia with nitrous oxide pneumoperitoneum: a feasibility study. Surg Endosc. 2003;17(9):1426-1428.\u003c/li\u003e\n \u003cli\u003eImbelloni LE, Beato L, Beato IC, et al.\u0026nbsp;Spinal anesthesia for laparoscopic cholecystectomy: thoracic vs. lumbar technique. Rev Bras Anestesiol. 2011;61(6):695-700.\u003c/li\u003e\n \u003cli\u003eBhattacharjee HK, Jalaluddin MA, Bansal V, et al. Feasibility of laparoscopic cholecystectomy under spinal anaesthesia: a comparison with general anaesthesia. ANZ J Surg. 2014;84(5):353-357.\u003c/li\u003e\n \u003cli\u003evan Zundert AA, Stultiens G, Jakimowicz JJ, et al. Segmental spinal anaesthesia for cholecystectomy in a patient with severe lung disease. Br J Anaesth. 2006;96(4):464-466.\u003c/li\u003e\n \u003cli\u003eLawrence VA, Hilsenbeck SG, Mulrow CD, et al. Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. 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Anesth Analg. 2001;93(4):853-858.\u003c/li\u003e\n \u003cli\u003ePark WY, Thompson JS, Lee KK. Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study. Ann Surg. 2001;234(4):560-569.\u003c/li\u003e\n \u003cli\u003eBisgaard T, Kehlet H, Rosenberg J. Pain and convalescence after laparoscopic cholecystectomy. Eur J Surg. 2001;167(2):84-96.\u003c/li\u003e\n \u003cli\u003eJoris J, Thiry E, Paris P, et al. Pain after laparoscopic cholecystectomy: characteristics and effect of intraperitoneal bupivacaine. Anesth Analg. 1995;81(2):379-384.\u003c/li\u003e\n \u003cli\u003eRawal N. Epidural technique for postoperative pain: gold standard no more? Reg Anesth Pain Med. 2012;37(3):310-317.\u003c/li\u003e\n \u003cli\u003eKehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367(9522):1618-1625.\u003c/li\u003e\n \u003cli\u003eHunt CO, Naulty JS, Bader AM, et al. Perioperative analgesia with subarachnoid fentanyl-bupivacaine for cesarean delivery. Anesthesiology. 1989;71(4):535-540.\u003c/li\u003e\n \u003cli\u003eBen-David B, Miller G, Gavriel R, Gurevitch A. Low-dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery. Reg Anesth Pain Med. 2000;25(3):235-239.\u003c/li\u003e\n \u003cli\u003eBessa SS, Katri KM, Abdel-Salam WN, et al.\u0026nbsp;Spinal versus general anesthesia for day-case laparoscopic cholecystectomy: a randomized, double-blinded controlled study. J Laparoendosc Adv Surg Tech A. 2012;22(6):550-555.\u003c/li\u003e\n \u003cli\u003eDonmez T, Erdem VM, Uzman S, et al. Laparoscopic cholecystectomy under spinal-epidural anesthesia vs general anesthesia: a prospective randomised study. Ann Ital Chir. 2017;88:446-451.\u003c/li\u003e\n \u003cli\u003eGlance LG, Lustik SJ, Hanish A, et al. The Surgical Mortality Probability Model: derivation and validation of a simple risk prediction rule for noncardiac surgery. 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Philadelphia, PA: Elsevier Saunders; 2015:1684-1720.\u003c/li\u003e\n \u003cli\u003eKoenig L, Gu Q. Growth of ambulatory surgical centers and surgery volume in the United States, 1990-2005. Health Aff (Millwood). 2013;32(9):1629-1636.\u003c/li\u003e\n \u003cli\u003eMelnick GA, Zwanziger J, Bamezai A, Pattison R. The effects of market structure and bargaining position on hospital prices. J Health Econ. 1992;11(3):217-233.\u003c/li\u003e\n \u003cli\u003eKehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248(2):189-198.\u003c/li\u003e\n \u003cli\u003eMiller TE, Roche AM, Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anaesth. 2015;62(2):158-168.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopic cholecystectomy, spinal anesthesia, comorbidities, regional anesthesia, minimally invasive surgery, high-risk patients, perioperative outcomes, patient safety","lastPublishedDoi":"10.21203/rs.3.rs-7801682/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7801682/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePatients with multiple comorbidities undergoing laparoscopic cholecystectomy face increased perioperative risks with general anesthesia. Spinal anesthesia may offer a safer alternative in this high-risk population.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo evaluate the feasibility, safety, and efficacy of laparoscopic cholecystectomy under spinal anesthesia in patients with multiple comorbidities.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis prospective observational study included 97 patients with multiple comorbidities (ASA II-IV) scheduled for elective laparoscopic cholecystectomy. Spinal anesthesia was performed using 0.5% hyperbaric bupivacaine (12.5\u0026ndash;15 mg) with fentanyl (25 \u0026micro;g). Primary outcomes included feasibility of procedure completion and conversion rates to general anesthesia. Secondary outcomes encompassed hemodynamic stability, pain scores, recovery parameters, and patient satisfaction.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eLaparoscopic cholecystectomy was successfully completed under spinal anesthesia in 89 patients (91.8%). Eight patients (8.2%) required conversion to general anesthesia, primarily due to severe shoulder pain (50%) and patient anxiety (25%). No mortality occurred. Hypotension developed in 24 patients (24.7%) and was effectively managed. Mean postoperative VAS pain scores were 2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 at 2 hours. Median time to mobilization was 4.2 hours, and 42 patients (43.3%) were eligible for same-day discharge. Patient satisfaction scores averaged 8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 out of 10. Patients with higher comorbidity burden (Charlson Comorbidity Index\u0026thinsp;\u0026ge;\u0026thinsp;5) had similar success rates but slightly higher conversion rates (10.7% vs 4.9%, p\u0026thinsp;=\u0026thinsp;0.284).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eLaparoscopic cholecystectomy under spinal anesthesia is feasible and safe in carefully selected patients with multiple comorbidities, offering superior pain control, faster recovery, and high patient satisfaction with acceptable conversion rates.\u003c/p\u003e","manuscriptTitle":"Laparoscopic Cholecystectomy Under Spinal Anesthesia in Patients with Multiple Comorbidities: A Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-06 04:17:08","doi":"10.21203/rs.3.rs-7801682/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"96e6262d-7810-442f-b9d8-ff2765b8228f","owner":[],"postedDate":"November 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T04:39:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-06 04:17:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7801682","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7801682","identity":"rs-7801682","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}