Position: Supine
Time: 30-60 min (short)
Blood Loss: Low (10-50 ml)
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: No

Approach – Existing epidural or a single-shot spinal.

Epidural Use – If the patient delivers using an epidural, there is an option to leave the epidural in with saline running at a slow, continuous rate to maintain the patency of the catheter. As long as the surgery is scheduled within 24 hours of the delivery, the existing catheter can be used for bolusing. Leaving the catheter in place longer than this comes with increased risk of catheter migration or infection. If bolusing an existing epidural, you want to assess whether the epidural worked well during their labor and delivery (meaning they had a good level of block and it was bilateral). Aspirate the catheter to make sure it hasn’t migrated intravascularly. A test dose (3-5cc of lidocaine with epinephrine) is also recommended to ensure the catheter has not migrated intrathecally. If the catheter is in place and running well, bolusing with 5cc at a time of lidocaine (2%), bicarb, and epinephrine at a 20:1:1 ratio, will allow a block level of T4-T6 to be achieved.

Spinal – If your institution does PPTL without using laparoscopic instruments, a good approach is a single shot spinal. A spinal approach at L4-5 level using 0.5% bupivicaine mixed with fentanyl and/or morphine will last around 2 hours and provide adequate surgical anesthesia during the procedure. Morphine can be excluded for a shorter acting block depending on estimated surgical time. With this surgical approach typically three small incisions are made, one right above the belly button and two off to the sides. Sometimes the spinal dose does not cover the entire belly button and the surgical team will have to supplement with some additional lidocaine for skin incision.

Block Level – T6 to T4 for this procedure. Check the level of sensation using cold spray or a blunt needle before the surgical team preps and drapes the patient.

Additional considerations – blood pressure can precipitously drop with spinal medications and a phenylephrine pump is a good option to ensure the patient has a stable MAP during the procedure. Using a dosage of 160mcg/ml, starting a pump at 0.5mcg/kg/min. Otherwise, a bolus syringe of phenylephrine can be used.

Breastfeeding (general considerations): Advice to temporarily refrain from breastfeeding and discard their breast milk for 24 hours following anesthesia administration to prevent medication transfer to the infant may be outdated. Breastfeeding can continue after anesthesia if the mother is alert, awake, and capable of holding her baby. Postoperative codeine and meperidine should be avoided in the lactating mother. Hydromorphone should be used with caution. As a general rule, mothers should closely monitor their infant for signs and symptoms of behavioral changes while taking medications.