Expert: JM Starkman, MD - 9/18/2009

Question
Hi doctor.  I lost 100lbs a few years ago (now I'm in excellent health), but now I need full abdominoplasty because fo the excess skin and loose muscles.  I have been told that the surgery is several hours long.  I don't want to have it if I'm likely to have PONV.  The local surgicenter does a lot of these and told me that gen anesthesia is required since I can't do spinal because of previous injury. I accompanied a nurse friend of mine who had the same surgery and she asked about the PONV, they use sevo, nitrous, fentanyl and told her that PONV would be unlikely.  She had such severe PONV that she had to get admitted; the recovery room nurse is my neighbor and said that about 1/3 of patients who get sevo and nitrous have moderate PONV or worse despite ondansetron (SP?)... I was reading that TIVA using propofol/remifentanyl almost never produced PONV; could this be used for my full abdominoplasty?  I tried to ask the anesthesiologist at the surgicenter and he said that he would only talk to me on the day of surgery.  When I cancelled my procedure (and requested my money back), the surgeon calle me and said that I could now speak with the anesthesiologist; she didn't know if TIVA could be done here, she's originally from the UK and said that they have special pumps (TCI) or monitors for something called "targeted controlled infusion" in the UK for TIVA but that this might not be available in the USA.  I appreciate your comments, I'm obviously not going to get a reliable response from the surgicenter, although they are much nicer since I asked for my $10K deposit back.  Thanks.

Answer
There are many more issues in avoiding PONV than solely the agents chosen for the anesthetic, and these have been exhaustively reviewed in the anesthesiology literature for many years.  An anesthesiologist who is interested in this matter and seeks to address his patients' needs individually to avoid PONV usually can be successful in doing so---but a guy who "will only see you the day of surgery" is NOT that guy, so you did precisely the right thing by getting your money back.  Go elsewhere.

Propofol/remi might work well for you, but I think a gen anesthetic is safer for this type of surgery.  And anyone "trying" out this technique for the first time on you could easily overshoot the remi, which is a narcotic and will cause nausea and vomitting sooner or later in almost everyone....especially if it's with a TIVA and you're retaining carbon dioxide......or slightly acidotic......or the surgeon needs you "deeper" to improve muscle relaxation to expedite his closure of the abdominal wall....it all gets complicated quickly.

There are many good surgeons and anesthesiologists doing these type of surgeries--and there's no rush to proceed.  I'd keep shopping around until you can find a team that meets your (patient AND customer) needs!