I Wanna Be Sedated! Anesthesia Options for Pilonidal Surgery

First, Let’s Define Our Subject

Anesthesiology is the practice of medicine dedicated to the relief of pain and total care of the surgical patient before, during and after surgery.
A great video explanation https://www.youtube.com/watch?v=B_tTymvDWXk

The Goals of Anesthesia

Amnesia (you won’t remember a thing)
Analgesia (blockage of pain)
Hypnosis (a state resembling sleep)
Muscle Relaxation (oh, yeahhhhh)
Anxiolysis (sedation)
Antiemetic (reduce nausea)

Your Anesthesiologist

Usually, you will meet your anesthesiologist in the pre-op area before your surgery. Prior to surgery, the anesthesiologist will discuss your options with you and together you will make a decision about which type of anesthesia to use based on your medical history, allergies, overall health, previous reactions to anesthesia, and type of surgery being performed.

In most cases it is that anesthesiologist, not the surgeon, who makes the decision about which type of anesthesia you should get. He/she is the sedation professional that takes you down the pathway to bliss and the one who monitors you all through surgery until you emerge on the other side. The surgeon is there to cut and sew, the anesthesiologist is there to make the procedure as comfortable for you as possible.

Eating & Drinking

Decades ago it was recommended that patients not eat or drink anything after midnight prior to surgery to reduce the chance of vomiting under general anesthesia. In 1999 the American Society of Anesthesiologists issued updated guidelines that allow patients to take clear liquids (water, fruit juices without pulp, clear tea and black coffee) up until 2 hours before surgery and a light meal up to 6 hours prior. Many surgical facilities are still issuing the old instructions of not eating after midnight; however, studies have shown that this dehydration may actually increase post-operative discomfort.

Some more extensive types of surgery may require longer fasting periods. If you have received instructions from your surgeon which differ from the ones listed below, please follow those instead.

Adults & Children Older Than 3 Years of Age:

A full meal is allowed up to 8 hours before surgery.
A light meal (toast, milk, orange juice) is allowed up to 6 hours before surgery. No fried or fatty foods like sausage and eggs.
Clear liquids (apple juice, water, black coffee, tea, clear broth) are allowed up to 2 hours before surgery. No milk or lattes.

ANY surgery is scary! Want to make the experience actually enjoyable? We thought you might…ask your anesthesiologist for some “Versed” — better known as the “happy to go with you drug”. You will be giggling, giddy and ready to do wheelies in the hallway when they roll you off for surgery. CathyK from the forums reports that she was singing in pre-op before her surgery!

Your Anesthesia Choices

There are 3 choices when discussing anesthesia for excision surgery. Many people are uneasy with traditional General Anesthesia since it has a long history of problems and sometimes fatalities. For this reason I have listed anesthesia choices in the order of preference based on safety and appropriateness for this type of surgery. The final decision is between you and your anesthesiologist.

“MAC” – Managed Anesthesia Care

Also referred to as: local anesthesia with sedation, procedural sedation, twilight sleep, conscious sedation

What it is: it is conscious sedation with local anesthesia (a medically controlled state of consciousness) In simpler terms; the surgeon injects the surgical site with a local anesthetic while the anesthesiologist gives sedation intravenously (IV) and monitors patient’s safety and comfort during the operation. This form of anesthesia has the quickest recovery time and the fewest aftereffects. It is considered safer and superior to General Anesthesia for many types of surgery.

How it effects your body: one of the primary benefits of MAC is the lessened overall impact on the body. Also the anesthesiologist has much more control over the individual components (sedation, muscle relaxation, hypnosis, amnesia) since MAC is a kind of a “cocktail” and each drug is administered individually via the IV drip and each drug can be adjusted individually.

What will you feel: you shouldn’t feel a thing and your anesthesiologist will be right there to make sure you don’t. You will be in a semi-conscious state, able to respond to commands, but you will have no sensation of pain and no memory of the operation. Every person reacts individually to different drugs so you may still experience some nausea, but the likelihood is much less than with General Anesthesia.

Notes from our message board users:

Hoosier says,”GET THE MAC!”

“Well, I’ve been out of surgery for about 8 hrs now. Let me say I’m now a big fan of sedation with local anesthesia. I made the mistake of reading the personal experiences section on this site last night, so I was a little nervous about the operation. In pre-op the anesthesiologist hooked up an IV and said she was giving me some “top shelf” drugs to relax me. The next thing I knew I was waking up in recovery. A little dizzy, but no nausea or pain.”

Spinal Block

Also referred to as: Regional Anesthesia

What it is: this a method of numbing the lower half of the body by injecting anesthetics into a sac of fluids in the lower back which contains the spinal nerves. This is similar to an Epidural used for childbirth, the only difference is that with an Epidural, a catheter is put into the lower back so that continuous does of drugs can be injected over longer periods of time. Spinal anesthesia typically wears off in 2 – 4 hours, which is not a happy thing if you are going through 10 hours of labor…

How it effects your body: the anesthetic blocks the nerves in the lower half of the body and you will be immobile from the waist down. If you opt for sedation in the IV drip you will also get the benefits of being in happy-land at the same time.

What will you feel: nothing below the waist! You will have the option be given sedatives through an IV as well, or you can decide to go without and be completely awake. A thought to keep in mind as you make this choice — Pilonidal excision surgery takes place with the patient in what is known as the “jack knife position.” Picture yourself bent at the waist with your rear end sticking up where the person with the scalpel can get at it easily. And your buttocks pulled apart with tape. You won’t be able to see anything but the floor and your surgical team’s shoes… If you want that delightful memory in the back of your mind then your are braver than us!

Notes from our message board users:

“The spinal bloc was an injection into the base of my spine. The area was give a topical anesthetic first and I didn’t even feel the injection. I too had expected this to be the worst part, but I didn’t feel a thing. YIPPEE!!!!!! After the injection I had to sit up for a few minutes until I was completely numb from the waist down. They (the nurses, Dr, and anesthesiologist then rolled me onto the operating table and the surgery began.”

“Right after the shot I felt light headed, but not dizzy. As predicted, one of the side effects was a headache, but only a slight one not even needing as aspirin. I was awake during the surgery and had a nice chat with the surgeon, nurses and anesthesiologist. After they had been at work for what seemed like only a few minutes, I asked for status – the cyst was already out and the surgeon was cauterizing the bleeding. I could feel some little “pricks” in the surgical area and he said it was the electrical charges used to stop the bleeding. Interesting!!!”

“I was able to eat a bit of crackers and juice immediately upon returning to the recovery room, and spent most of the recovery time reading a book and then chatting with friends who’d come to take me home. When I asked the anesthesiologist what the down-side to the spinal bloc was, he said that it was only an elongated stay in the recovery room; that I would not be released from the hospital until all of the numbness went away. Two hours after I entered the recovery room, I was able to walk alone and was able to go home.”

“It’s hard to say that someone else would have the same good luck as I did with this spinal bloc, but if asked my opinion I would recommend it strongly over a general. The other aspect is that I only had one giant cyst, and not repeated surgeries, multiple cysts and sinuses. This might make a difference.”

General Anesthesia

What it is: gas that is inhaled by face mask while drugs may be fed intravenously. A breathing tube is usually placed in the throat. This is the most complicated form of anesthesia and has a much greater effect on the body than MAC or Regional (Spinal Block). Usually you will be given a sedative in your IV before breathing from the gas mask. The breathing tube will be placed after you are unconscious.

How it effects your body: you will be rendered completely unconscious. General Anesthesia can be hard on the body and nausea/vomiting is a common after effect. Since this anesthesia is inhaled, changes in all patients lungs occur during General Anesthesia and lung function is worse for about 48 hours after surgery. General Anesthesia also takes longer to wear off than MAC, so you’ll be in the recovery room longer.

What will you feel: nothing during surgery. Post surgery there may be some discomfort from the breathing tube (which will be removed before you go into the recovery room.

Medical Abstract Pulled From Pubmed

Local anesthesia and midazolam versus spinal anesthesia in ambulatory pilonidal surgery.

Journal of Clinical Anesthesiology.
May 2003 Sungurtekin H, Sungurtekin U, Erdem E.
Department of Anesthesiology and Department of General Surgery, Pamukkale University School of Medicine, Denizli, Turkey

To evaluate two anesthetic techniques, namely, local anesthesia with sedation, and spinal anesthesia, with respect to recovery times, postoperative side effects, pain scores, patient satisfaction, and hospital costs for ambulatory pilonidal disease surgery .Prospective, randomized study. University Hospital of Pamukkale.60 consenting patients scheduled for pilonidal disease operation with Limberg flap technique .PATIENTS WERE RANDOMLY ALLOCATED INTO TWO GROUPS: Group 1 (n = 30) received spinal anesthesia with hyperbaric bupivacaine 1.5 mL 0.5%, and Group 2 (n = 30) received local infiltration with a 50-mL mixture containing 10 mL bupivacaine 0.5%, 10 mL prilocaine HCl 2%, and 30 mL isotonic solution with 1:200 000 epinephrine in combination with intravenous (IV) midazolam sedation.Perioperative and postoperative side effects, patient satisfaction, preoperative visual analog scale (VAS) pain scores, and VAS scores from the fourth hour postoperatively until the seventh day were assessed. Anesthesia, operation, surgery, and total hospital time, and costs (drug, resources, and labor) were recorded.No difference was found between groups in the frequency of side effects. Urinary retention was diagnosed in two patients in the spinal anesthesia group. There was no statistical significant difference seen in satisfaction scores between groups. No statistical significance in VAS pain scores between groups was noted except for the fourth postoperative hour values. The average time spent in the operating room (OR) was greater in the spinal anesthesia group. All Group 2 patients achieved fast-tracking criteria in the OR and were able to bypass the postanesthesia care unit (PACU). Total hospital time and total cost were significantly higher in the spinal anesthesia group than local anesthesia-sedation group (p < 0.05).The use of local anesthesia-sedation for ambulatory anorectal surgery resulted in a shorter hospital time, lower hospital costs, and no side effects compared with spinal anesthesia.

Additional Reading

How Anesthesia Works