Unsedated surgery - building a case and getting ready

Background: I have a varicocele that I really should get fixed. I'm still able to function, but it's making be grouchy and mean and I'm cursing and snapping at the family. Productivity is down and I'm using Tylenol/Advil on a daily basis. I'm also beginning to suspect that the ongoing pain might be a factor in my IBS.

Problem: there's no way that I'm letting them use general or sedation. Last time was living nightmare type stuff, at least for me. I know that this can be technically done on a spinal - after all they do cesareans on a spinal or epidural, but I also know that the doctor will need some convincing. I also want to know that I can do it before I go in. I'm almost sure I can - I have no problems watching with needles and blood, and I do poke around if I cut myself to see if I see anything interesting, but I want to do my homework here, get myself ready, and present a good case.

So far I have read up on the procedures and how they're done, and am watching videos so I know what to expect. From the vids I expect that I'll need to be able to lie still for 15-25 minutes (I will verify this), though with the lower half of my body knocked out I imagine that shouldn't be too hard. What else should I prepare, study, practice and be able to "prove" so I can build a strong case to myself and the doctor that this is doable?

Any other tips on approaching a doctor with a request like this that seems like it is outside of their usual practices?

The surgeon won't need convincing. You'll have to convince the anethesiologist. Shouldn't be a difficult conversation. If you have any medical contraindication for spinal, that will be another story. Expect to stay much longer for the spinal to wear off. Sedation is usually faster, in and out. They'll probably want you there in the morning, not late afternoon, so staff does not have to stay overtime until you can walk. There may be a cost differential depending on your policy, should you have one.

Reasons to agree to spinal might be: Patient choice, patient with a difficult airway, patient with a 'bad' (perceived or otherwise) reaction to general, panic or anxiety making general impossible (patient would refuse but perfectly ok with spinal), lung disease (might include asthma/COPD/Smoking/emphysema). You can also choose spinal with NO additional relaxing medication, which is typically used. Epidurals can be 'spotty' and you might find you feel some areas; however, they do wear off faster - generally - depending on the meds used.

Good luck.

You shouldn't have to build a "strong case".. And please do not make up stories to tell the anesthesiologist. Be honest with your medical history!

Easiest way to get this fixed with spinal anesthesia is ASK YOUR UROLOGIST. Directly. Don't beat around the bush, don't make shit up. Ask him "can you do this under spinal anesthetic?" He will either say yes or no.

If he says no, ask him why. He may have a reason. If he doesn't have a reason, call another urologist. If he says yes, let him know that's what you want.

Now wasn't that easy?

Hope it goes well..

Doc

I guess I'll try the direct approach. I had asked earlier and been rebuffed, but local and spinal (though not by name) were being thrown around and I think there might have been some confusion. Watching the videos it's obvious why they wouldn't want to do local. In the second appointment where surgery started to be discussed the urologist seemed very pro-general, and a bit reluctant to entertain other options. That might mean that I need a different urologist, though I like that this one doesn't rush to surgery.

I'm not interested in making up a story. What I'm trying to do is address any concerns from the doctor, such as "we're worried you'll freak out when you see blood" or "you might not be able to hold still long enough" by being able to say "I did ___ (lay still for 25 minutes, yadda yadda) and it seemed to be OK". I know exactly why I'm not interested in general or sedation, and it isn't a made up story. My concern is that the doctor will give some variant of "we're doing it with you drugged somehow or you're living with the varicocele" because it's most convenient for them. Last time I was told a variant of "well nobody does that", when I pointed out that anesthesia before was a little dicey the reply was "we really know what we're doing", and a reply after I finally recovered was "what are you bothered about, you didn't die did you?"

I had a AAA repair under heavy sedation. They took me back for the repair of a leaking femoral artery, again under heavy sedation.

I don't recall what they did to eliminate pain, but I felt no pain during surgery. I could feel rinsing with cold saline and felt tugging on my abdomen, but no pain. The thing that hurt most was my spine from laying still on the OR table for a long period of time. I also felt them insert a Foley into me and could hear voices. I have to assume that this was done under local anesthetics. Post op they gave me small injections of morphine for my back pain, but not for abdominal pain. I was surprised that they did all this without a general anesthesia.

Yeah, it should be just fine with some sort of a regional block. I have a relative who had carpal tunnel done, and she said there was a dragging sensation as they cut in but that was it. I just need to make sure that I can address any concerns that the doctor has and I'm not going "unh, maybe, I think so..."

I would have said "let's start out this way, and if necessary you can sedate or do general later" but frankly, after last time I don't trust anesthesiologists beyond what is explicitly worked out beforehand.

It is perfectly acceptable to work out your options with the urologist and the anesthesiologist and then PUT THEM IN WRITING.

You can outline choices, in order of preference and include "if this, then" options that are consistent with what they would normally do anyway and/or what they've agreed upon. The real purpose is to clearly record what was agreed by everyone so there's no "bait/switch" when there's no turning back.

Be careful not to list anything as "NFW - no matter what" because any responsible physician can't be put in that position if it ends up your life is at risk. Their malpractice insurer could refuse to insure them for your case, or refuse to cover them if you (or your estate) sues them, even though they explicitly followed the agreement. One way to protect everyone is to make sure that you have someone PRESENT with medical power of attorney (or state equivalent) who can be consulted before they resort to a general (assuming there is time and you're not dying).

Just for context, I'll add that there are many, many hospitals that will directly ignore an Advanced Directive, DNR and similar restrictions out of fear of litigation. [Sometimes the staff will admit it, sometimes they won't.] I've had this confirmed a number of times in discussions with ICU, CCU and Cardiac nurses. The hospital's argument is that they can be sued if you die, but not if you live - even if living becomes a living hell for you. This is not the same, of course, but the hospital's policies should be checked, as well, and that's my point. Physicians have to respect hospital policy (to a point) in order to preserve their privileges at that hospital. If the surgery can be performed in a surgery center, you would probably have more certainty about how that all can be managed to your preferences.

(Note: I am not a lawyer and this is not legal advice. I do work in health care management consulting and am familiar with these matters. In addition, I have served as a P of A twice for relatives.)

Had prostate and bladder surgery same time and went for spinal instead of general. Was awake for most of it talking to doctor as what was going on. All was going well until I started to react to the morphine used in the spinal . That was about three hours into surgery. They gave me something to knock me out. I quess I was a bear until that happened. Anesthiologist said I broke Velcro straps holding my arms down and broke surgery table. No recollection of that thank goodness.

I had a hernia operation done under local anesthetic. I told the anesthesiologist I wasn't nervous & didn't need anything. I really wanted to experience the prep. So far so good. The surgeon asked, "You're sure you don't want sedation?" NO. The injections HURT! OK I'm a wimp. I begged for the juice and the anesthesiologist stuck something in the IV. Next thing I knew the surgery was half over. I had no hangover from the sedation and was discharged an hour and a half post op.

The varicocele surgery is done in the groin just a little lower than a hernia. I can see no reason it can't be done local.

You may NOT list real physicians in the forum.

If you like you can discuss physicians by personal message.

Yep, local burns big time, but then it's calms down. I've read some "general doctor" or slightly above level stuff and it seems as though the consensus is that if necessary varicocele repair can be done under local, but it's pushing it and regional/spinal or general is "safer" as far as avoiding pain break-through (and it would be very hard to interrupt the surgery to do a spinal later), so I'm OK with it not being local.

Building courage... still in the "I'm not dead yet ... I'm getting better" phase of delusion, but recognizing that it really isn't the truth. Set a personal deadline of sometime this year to put up or shut up ... we'll see...

I think the overkill banter on this topic is becoming the fetish. Either find a urologist who uses an anesthesiologist who can do spinal yes/no, or move on.

https://www.ncbi.nlm.nih.gov/pubmed/16281094 This research showed hundreds of men had their varicocele under local, so if control is your issue, suck it up. Hundreds of thousands of women have abortions under local each year and do just fine, so I have no sympathy at this point.

Thank you, enemasubgirl. That article strengthened my argument significantly, as it now includes a more general argument.

I don't think they'll go fully local in the US because they don't want to stop and re-anesthetize if pain starts breaking through (this was an Asian study), but a regional block/spinal will work just fine and will still have "reduced morbidity...and adverse effects" and a more rapid return. Strong argument, if they don't buy it I'll hit them with "if you won't then give me a referral".