General vs local anaesthesia
April 1, 2014 7:00 AM   Subscribe

Why give general instead of local anaesthesia for minor knee surgery?

Mr. McCatburglar will be having surgery for a torn meniscus later this month. He went in for the pre-op consultation with the anaesthesiologist today, and they said he would be having general anaesthesia because of "better recuperation". I've always thought that general anaesthesia was a bigger deal and brought with it a lot of other complications, and therefore local was preferrable.

The internet seems to think that local, spinal, or general are all standard for this type of surgery. So what could the doctor have meant by "better recuperation" with general anaesthesia?

NB: this is my translation of Mr. McCatburglar's report of what the doctor said, so there could be some crossed wires here.
posted by lollymccatburglar to Health & Fitness (13 answers total)
I've had this done 3 times, all with general. In my experience you're just out, then awake and it's done. Then you go home and find a couch and lay there half asleep and not moving much for the entire day. The next day they want you up and moving on it to reduce scar tissue buildup.

I'm guessing that 18-24 hours of vegging on the couch if more beneficial than just having it numbed and done and feeling in your right mind, thinking that it doesn't hurt so much, so why not do a few chores around the house or something.
posted by sanka at 7:22 AM on April 1, 2014 [2 favorites]

That's a question that needs to be asked of the surgeon and the anesthesiologist. I will say, that I was a 100% card-carrying 'local only' person, right up until I went under for the first time. Do you know how great it is to say 'night-night' while being wheeled into surgery, and then to wake up, under a warm blanket to a nice recovery nurse?

So much of surgery is the anticipation of pain and unpleasantness. A good general anesthetic can really, really make surgery SO much easier. (I've had it twice)

There are also twilight sedation, like Versed which one gets pre-operatively, and it is SO GREAT!

On the morning of surgery, you will be allowed to hang with Mr. McCatburglar, I have found that anesthesiologists and doctors want everyone to be comfortable and happy and will answer any questions that you may have.
posted by Ruthless Bunny at 7:23 AM on April 1, 2014 [1 favorite]

Well, this is a guess, but local anaesthesia makes surgery harder for the surgeon because awake patients have needs, react to things by moving, need to pee...
posted by the young rope-rider at 7:38 AM on April 1, 2014 [2 favorites]

Someone fully under anesthesia is more completely relaxed, which makes moving muscles, tendons and bones easier as there is less resistance, which leads to less bruising and damage to other parts. I am basing this entirely on something a vet said when fixing a dogs hip so make of it what you will.
posted by wwax at 8:34 AM on April 1, 2014 [2 favorites]

I think it comes down to whether you would rather be a moveable, immobile lump that the surgeon can move around, or if you would prefer to be conscious while someone chops your body open and you're trying very hard to be still and not frightened or bored, and you don't mind that you will remember someone chopping you open.
posted by mikeh at 8:45 AM on April 1, 2014 [7 favorites]

Even minor surgeries, performed under local, can be really disconcerting, even if they aren't painful (you can guess how I know). I wonder if the meniscus surgery is like that, and the doctor is just BSing Mr McCatburglar.
posted by adamrice at 9:18 AM on April 1, 2014

Having recently had (somewhat more involved) knee surgery, I went under general and am very glad I did. I read the surgery notes. Your leg needs to be put into traction to open up the joint, exsanguinated through tourniquet and then they can start like, cutting you open and messing about with moving around your tendons out of the way, and generally put you in a position reminiscent of butchering down a whole chicken into fryer parts.

Pain, recuperation, thinking about yourself as "injured"—it's all a mental game. It really really is. Having less knowledge of things is better. Waking up and being "fixed" is the way to do it. You don't need that anxiety, which will increase your pain, slow your healing, and make you think of yourself as injured/defective.

I was pretty worried about having general. I was not nauseous at all—antiemetics are awesome, and they were administered before I woke up. I had dinner a few hours later, had normal conversations, etc. (Again, my surgery was way more involved, the meniscus was the minor part, and I stayed overnight) Your medical history will determine if you have more risks that would make you more susceptible to side effects of general anesthesia (like cardiac issues). I was also surprised to learn that you don't necessarily need to be intubated under general, which can also reduce risks.

I'll say it again, recovery, positive attitude, pain—it's not 100% in your head, but your brain can act as a huge amplifier, turning the volume up or down. Having general with amnesia induced is the best way to keep your mind on an even keel. I might even go so far as to not discuss your doubts with your spouse any further. Be the happy supportive partner. Have faith in your doctors. Be a physical therapy cheerleader.
posted by fontophilic at 10:25 AM on April 1, 2014 [3 favorites]

I'm somewhat shocked that any surgery other than a c-section is given under anything other than general anesthesia, and I think that's only because of the momentousness of the occasion of birth (I know, many c-sections are done under general, but epidural is the standard). I have memories of my c-section that I can never, ever get rid of, and I kind of wish that I had been under. I had general anesthesia for oral surgery, and will be asking to be knocked out for anything other than another c-section.
posted by peanut_mcgillicuty at 8:27 PM on April 1, 2014

You should be aware that versed/midazolam can have horrible side effects for a small percentage of the population. I was in excruciating pain but unable to communicate for an entire procedure and had an uneasy feeling and nightmares for a month. If you read about it online and look at even more horrifying things can happen.
posted by meepmeow at 9:08 PM on April 1, 2014

One piece of information I forgot to include in my question: we've had two friends recently undergo the same procedure, and both of them had local anaesthetic. That's part of the reason why we were curious about Mr. McC's situation.

Good answers, I think you all are right about the awake patient accidentally interfering with the surgery by moving around, and that it is better psycologically to be unaware of what is happening to your body.
posted by lollymccatburglar at 1:21 AM on April 2, 2014

I asked my husband to answer this, as he's an anesthesiologist who is having this procedure done to himself next month. Here's his answer:

Knee arthroscopy cannot generally be performed under local anesthesia alone because this will provide inadequate analgesia (pain relief) and will allow too much movement of the knee joint and muscle tension to adequately distract the knee joint.

Neuraxial anesthesia (spinal) and general anesthesia are both reasonable approaches. Typically general anesthesia is used because recovery is often faster than spinal anesthesia. This is typically a short procedure (45 min to 1 hour). A spinal anesthetic can be used for patients who wish to be awake and able to watch the procedure, as well as for patients who have severe comorbidities which would increase their risk from general anesthesia, but who do not have a contraindication to a spinal anesthetic.

For more complicated and painful arthroscopic knee procedures, such as ACL reconstruction, a longer lasting nerve block (in this case of the femoral nerve) may be used for post-op pain control, but for a meniscus repair or debridement most would consider a nerve block to be overkill (and hence insurance companies would not pay for it).
posted by Capri at 3:56 AM on April 2, 2014 [1 favorite]

For a different type of knee surgery, I was told that the surgery isn't the problem, the problem is the tourniquet used. People can't handle that.

I've had twilight or topical/local for other things, but they don't bend for invasive knee surgery. Depending on the procedure, they may need to use a tourniquet.

I'd press a little though - the reason may be more about SOP than any reason.

Has the spouse had other things done without the miracle of modern drugs? Dental work, cyst removal, re breaking a mis-set bone? If yes, maybe he's a candidate for something less than full-on sleepy time.
posted by Lesser Shrew at 12:15 PM on April 2, 2014

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