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Surgery Under Hypnosis

Recurrent laryngeal nerveThe BBC recently reported that a Guinean singer, Alama Kante, sang through her surgery in order to protect her voice. The reporting is unfortunately typical in that it emphasizes the seemingly amazing aspects of the story without really trying to put them into proper context. Specifically, the story emphasizes that hypnosis was used during the surgery, since Kante could not be placed under general anesthesia and still be able to sing, reporting:

“The pain of such an operation is intolerable if you are fully awake. Only hypnosis enables you to stand it,” he was reported as saying by to French publication Le Figaro.

“She went into a trance listening to the words of the hypnotist. She went a long way away, to Africa. And she began to sing – it was amazing,” he said.

Reports of major surgery being performed using self-hypnosis or hypnosis instead of anesthesia crop up regularly, because of the obvious sensationalism of such stories. I reported a similar case from 2008, for example. At least in this case the news report gave the critical piece of information, often missing entirely from such reports:

The Guinean singer, who is based in France, was given just a local anaesthetic and hypnotised to help with the pain during the operation in Paris.


She was given a local anaesthetic. Local anesthesia, when properly done, can completely block all pain and sensations from the relevant area. Why was hypnosis even necessary, then? Perhaps it wasn’t, but hypnosis, self or otherwise, can be useful as a means of calming anxiety or distracting a patient from the procedure. Even with local anesthesia, a patient may still feel pulling and poking and this can cause anxiety.

Hypnoanesthesia might be a useful adjunct for surgical procedures where the patient is awake. The literature is not clear. But it is important to note how some define hypnoanesthesia – as “hypnosis, local anesthesia and minimal conscious sedation.” It isn’t certain what role hypnosis is playing when both local anesthesia and conscious sedation are given. In this case the BBC report did not mention conscious sedation either way, so we don’t know if the hypnosis had any pharmacological help.

It is also not uncommon for patients to medicate themselves prior to surgery, by taking some of their prescription pain or anti-anxiety medication.

Published research looking at hypnoanesthesia has been mixed, plagued by poor methodology and not carefully separating out hypnosis and an independent variable. Those that do have a higher tendency to be negative.

It should also be noted that hypnosis doesn’t really involve putting people in a “trance,” even though that word is commonly used (as with the current BBC reporting). Hypnoanesthesia is mainly a form a deep meditation, which can be self-induced or guided by another. The person is still awake and alert, and not what people might imagine from movies or television as “in a trance.”

This can be a useful technique for distracting patients from the procedure and any uncomfortable sensations and reducing anxiety. Such techniques are as old as medicine itself. Every medical student learns how to distract patients from a painful procedure, engage them in small talk, and to calm their anxiety. This is just good bed-side manner. Hypnosis or self-hypnosis is just a formalized way to do this, without clear evidence that it is superior.

The theme of mainstream reporting on surgery with hypnosis, however, generally paints a very different picture, for sensational effect – that of a patient in a trance while surgery is being performed on them with little or no anesthesia. This is a fiction.

The other aspect of this story reported for sensational effect was that the patient, Kante, sang during the critical parts of the surgery to “save her voice.” The surgery was on the parathyroid gland. The risk with such surgery is damage to either the superior laryngeal nerve or recurrent laryngeal nerve (RLN), which can cause hoarseness or loss of voice.

While the incidence of temporary or permanent paralysis of the RLN is quite low, 1-4%, it is a serious complication when it occurs. The greatest risk is from bilateral RLN injury, which can compromise breathing.

Monitoring the function of the RLN during surgery is not a new idea, and there are numerous studies looking at this technique. This involves stimulating the nerve and measuring a response (so that patients can be under general anesthesia). RLN stimulation is not perfect, but does highly predict RLN damage from surgery. It does not prevent the damage from occurring, however. Its primary use is to detect RLN damage on one side before proceeding to surgery on the other side, in order to prevent bilateral damage (on both sides).

Kante’s procedure apparently is unique in that singing was used to detect damage to the RLN, rather than nerve stimulation. It’s not clear if this was at all useful in preventing damage to the RLN, just demonstrating that damage had occurred.

Conclusion

This story is of a singer who had parathyroid surgery under local anesthesia and didn’t suffer a complication that occurs 1-3% of the time and could have damaged her voice. News reporting focused on the two aspects of this story that may have had little or no impact on the procedure, the hypnosis and singing as a way of detecting damage to the RLN.

It is not clear if hypnosis is at all beneficial, but it is plausible that hypnosis during procedures in an effective strategy of relaxation and distraction (although not necessarily more effective than any other method).

Singing during the surgery to monitor the RLN seems like little more than a gimmick. There is already a method in place to directly monitor RLN function and detect damage. It is also not clear if such monitoring reduces the incidence of damage to the RLN, or just predicts it.

The BBC, however, did not let educating their readers about all the relevant facts get in the way of telling a compelling narrative.

Posted in: Neuroscience/Mental Health, Science and the Media

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37 thoughts on “Surgery Under Hypnosis

  1. Irène Delse says:

    Thanks for this post! I had read the original Le Figaro article in French a few days ago. It doesn’t even mention local anesthesia, though at the time I tweeted that I bet it was used for Ms Kante. It looks to me that tboth the French press and now the BBC just took the hospital’s press release and quoted large pieces of it without much inquiring about the facts. The phrase “in a trance” is in the original press release, for instance. I can also add, as background info, that the hospital where they did the surgery, Hopital Henri Mondor, is a pretty big and prestigious hospital and this brouhaha about an operation that is probably done in a lot of places each year sounds a lot like they are whipping it up for publicity, both of the hospital and of the surgeon himself.

  2. goodnightirene says:

    Sad to see the venerated BBC stooping to this, but it’s not the only example unfortunately.

  3. Bruec says:

    The reporting on the BBC seems to be getting worse and worse. In years past they would not have touched something like this, at least not as credulously as they did. I think the competition from the other more sensational news outlets is pushing them to try out more “sensational” stories.

    I will be writing to them this evening and will link to this article, if you don’t mind.

  4. Bruce says:

    Managed to spell my own name wrong… genius.

  5. PB says:

    Isn’t it possible that, if they did have her under “hypnosis” with local sedation (or whatever form of “hypoanesthesia” they may have used), that surgeons simply asked her to speak a few times during the surgery? Perhaps she even “sang” at a low level (some sort of humming?) and THIS was what was sensationalized by the articles?

  6. Andrey Pavlov says:

    Yet more terrible sensationalistic journalism.

    She was given a local anaesthetic. Local anesthesia, when properly done, can completely block pain and all sensation from the relevant area.

    At my institution we sometimes do entire hip replacements with the patient fully awake. A proper nerve block is all one needs. Brain surgery is routinely done with the patient awake. In both cases some sort of mild sedative is given purely to diminish anxiety and allow the patient to be more comfortable whilst being immobile for the duration of the surgery.

    The other aspect of this story reported for sensational effect was that the patient, Kante, sang during the critical parts of the surgery to “save her voice.”

    As Dr. Hall points out, this is bollocks. You can sing all you want but if the surgeon cuts the RLN it will stop your singing. That direction of causality only goes one way – singing does not erect a magical force field around the RLN so the scalpel bounces off of it should the surgeon get too near.

    I am not a surgeon, so I cannot comment on it fully, but I have scrubbed in on a few thyroid and parathyroidectomies. It is a tight space in there with a whole lot going on (which is why I never wanted to do ENT). I can only imagine that the vibration of her singing could have actually made things more difficult for the surgeon. I’d be willing to bet that at specific times during the surgery she was asked to stop singing, as surgeons generally tend to know anatomy reasonably well (:-P) and would prefer everything be as steady and still as possible when they are going into “danger areas” like near the RLN.

    Either way, nearly nothing about this story is useful or informative.

  7. Frederick says:

    This is an other good example of the side effect of the modern speed race to get the news out. Media Take less and less time to do proper validation of what is in the news items, they don’t want a competitor to get it out before them. The prisoners dilemma, They don’t know what the others media will do, so they do it just to be sure they are not left behind, in worst case, Or they are the first ones, in the best case.
    That’s exactly the kind of cases given as example In My Gerald Bronner essay.

    This is not a “dangerous” news, but it just show how media how less and less reliable.

    The funny thing is, that often conspiracy believers, and CAM advocate blame the media for “blinding” people, but in most cases the mainstreams media give them more spaces than science, and critical thinking without asking question. They Help them a lot in reality. Well they are right in the fact that media are not always helping in educating people, but not in the direction of critical thinking. this is depressing,

    1. Bruce says:

      My wife used to watch SKY news all the time. They would jump on a story before any verification had happened. I would always tell her to switch over to the BBC and wait and see if they say anything about it as that would give a good indication of the veracity of the story.

      I have weaned her of SKY, but sadly it seems the BBC is slowly degrading for whatever reason.

      It is interesting that this story is filed under Entertainment & Arts on the BBC website, I am not sure if that has any bearing on the quality of the science reporting.

      1. Windriven says:

        “They would jump on a story before any verification had happened.”

        What do you get if you cross SKY News with National Enquirer?

        Matt Drudge

  8. mouse says:

    From the standpoint of someone who enjoys reading and listening to science/medical journalism, this is disappointing.

    I have heard about neurosurgery (such as for seizures) being done with the patient awake. The surgeon can avoid affecting particular skills by observing the patients reaction when different areas of the brain are stimulated (?). Perhaps the journalist was confusing this surgery with that process? I’m not saying that’s a good excuse though.

  9. nutritionprof says:

    Many years ago I was “into” lots of “voodoo”-reiki, homeopathy, acupuncture-and I also became a board certified hypnotherapist. That means I read a book, took a class and wrote a paper-and of course paid for the privilege of doing so.
    I use my experiences when I teach my class on “skeptics guide to complementary & alternative medicine” (thanks to information from you all). The only thing I tell my students I’d ever trust is hypnotherapy-not to treat disease, but for relaxation. Why? Because it’s mind over matter-and, as I tell them, when you don’t mind…it doesn’t matter.

  10. Harriet Hall says:

    Anecdote alert! I have had two open breast biopsies under nothing but local anesthesia. I was offered conscious sedation to control anxiety, but refused it because I wasn’t anxious. I did fine both times without any hypnosis or other intervention, but during the first procedure the anesthesiologist carried on a lively conversation with me that kept my mind occupied, and during the second procedure, with no conversation, I was more aware of the tugging and pulling sensations, unpleasant but not painful. Later I refused the standard conscious sedation for a bone marrow biopsy and found that the local anesthetic was perfectly sufficient.

    I have been hypnotized and found it deliciously relaxing but didn’t think it was worth the time and effort for me to make it a regular practice.

    1. Windriven says:

      “I have been hypnotized and found it deliciously relaxing but didn’t think it was worth the time and effort for me to make it a regular practice.”

      My experience is identical. Nice enough but not special enough to seek out regularly.

    2. Frederick says:

      Is that true that some persons cannot be hypnotize ? That they are no subject to it?
      I never been hypnotize, I wonder if it could work on me. :-)

      1. Windriven says:

        It seems to be so – or at least that some are more difficult to hypnotize. JAMA/Archives of General Psychiatry has a free article from October, 2012 that addresses this.

        1. Windriven says:

          Sorry for the bad link – I was directing you to a downloaded version on my computer.

          Go here: http://archpsyc.jamanetwork.com/Issue.aspx?journalid=70&issueID=25059&direction=P

      2. Denise B says:

        Several qualified people tried to hypnotize me and nothing happened. I don’t think I can be. I started off not really believing it would happen, so maybe that’s why it didn’t.

        Interestingly, 23andme told me from my genome that I would be hard to hypnotize, but at the same time that I placebos would be more effective than average on me. Actually I think I have the opposite of a placebo effect; I never expect any treatments to help and I usually think they haven’t.

        I always thought these two things went hand in hand – lack of placebo affect and lack of susceptibility to hypnosis seemed to me to reflect an inability or unwillingness to take suggestion. So it was interesting to see that 23andme thinks the same gene would give me one and not the other.

      3. Jules says:

        Hypnotisability depends of the working definition of hypnosis. Standard scales have been developed to record levels of hypnotic suggestibility using a standard protocol and in that context some people are clearly more hypnotisable (suggestible) than others.

        With other definitions such as changes in subjective experience, we all tend to go into and out of various “trance” states throughout the day and while performing repetitive activities such as driving etc.

        I and many others who use hypnosis tend to view it more like a purposeful application and extension of placebo. A subject’s response to any suggestion is influenced by many factors and the greatest of those factors is the level of trust in the person making the suggestions. Just like a physician’s negative prognosis can increase a nocebo effect in the patient. Therefor much of the variability (IMO) in clinical studies to date may have to do with the variability in trust levels between the hypnosis practitioner and subjects in those studies. To my knowledge, there has been little standardization or control of those factors in common hypnosis research.

        The idea of hypnosis being some special state in which the subject is under the control of the hypnotist is rejected by many. Young brilliant practioners like James Tripp with his Hypnosis without Trance protocols are worth a look and the experiences are certainly more interesting than expected from a progressive relaxation protocol that basically bores the subject into submission and distraction.

    3. DevoutCatalyst says:

      Harriet, when you said no to conscious sedation was your refusal taken in stride each time or was there ever any resistance ? I had a gastroscopy with what I believe is the norm, just the topical spray, but I had to insist a bit on it. I got the impression this was unusual at our local rural hospital which wanted to use conscious sedation. Being able to drive myself home and go right back to work is a huge plus.

      What are the limits for such patient requests ? If I am ever faced with an appendectomy, can I insist on local ? Something tells me my preference will be ignored. But I so HATE general anesthesia !

      1. Harriet Hall says:

        They were surprised and skeptical, but readily agreed when I insisted. I asked why they wanted to use it and the only reason they could give was to relieve anxiety, and I explained why I was not anxious about those procedures. I reassured them that if they saw my blood pressure spike or observed signs of anxiety during the procedure that they thought needed treatment, they could sedate me then. I think they had been using conscious sedation just because it was the accepted routine. And I do think most patients want it and accept it unquestioningly. I don’t think a patient should ever arbitrarily “insist” on local; I think he should discuss the pros and cons with the anesthetist and surgeon. There may be other considerations.

        1. brewandferment says:

          When I got my first screening colonoscopy last year, I asked to try it non-sedated. The nurse that first checked me in seemed more than a little miffed when I made that request, as if I was somehow questioning his credentials. But the anesthesiologist (an NP I think) and the gastroenterologist were cool with the idea. I was clear that I was fine with everything being ready in case it became necessary. Since the last time I’d had any sedation was 19 years earlier with my eldest kid’s birth (Demerol, super-yuk!) I think the idea of sedation was more anxiety inducing than the procedure itself! I watched the video and chatted with the anesthesiologist/other staff person and it was just fine. Getting to skip out of there on my own two feet and drive home to a good lunch was so worth going without. I wish I hadn’t gotten the flack from the nurse but maybe it was just because I was varying from his checklist.

          This year when I had an ankle reconstruction, I went with sedation because when they put the warming blanket it was just so cozy and comfy that I couldn’t muster up the urge to say no to sedation, and indeed that was a longer procedure with more potential for general discomfort that made more sense. I found the sedation wore off pretty quick with minimal grogginess and no side effects that I could tell so now I’m less worried about it for future procedures–but I still prefer to attempt without for short procedures and just go with local.

          1. Chris says:

            “(Demerol, super-yuk!)”

            Ditto. It made the birth of second child miserable.

            “I went with sedation because when they put the warming blanket it was just so cozy and comfy that I couldn’t muster up the urge to say no to sedation,”

            I love the the cozy warming blanket. They gave me one before my last colonoscopy, and I think I dozed off as they sedated me.

            Even with the sedation my hubby said he was awake and observed his colonoscopy. Of course the stinker gets to wait ten years before he gets another one. Grumble grumble grumble.

            1. brewandferment says:

              demerol made me feel disoriented, drunk, AND hungover all at the same time. The real cause of much of my discomfort was the massive caffeine withdrawal I was having due to the ban on anything by mouth. I swear a shot of espresso would have fixed everything right up and I could have probably finished dilating pretty quick!

              It’s not fair to be hungover while still drunk!!!! I accepted hangovers as the cost of the party time, but that was just so wrong. And didn’t do much for pain either.

              1. Chris says:

                All I felt was lots of nausea. I just wanted to vomit the entire time. It is my typical reaction to any narcotic, which is why I am given anti-nausea medication when I have a procedure like a colonoscopy.

                I am not alone, I apparently react like one out of ten in the population. We are the group that would never hold up a pharmacy for narcotics, unless we decided to throw over a system by producing lots of vomit.

        2. MTDoc says:

          Though it is possible to perform an appendectomy under local, it certainly complicates the procedure, and I for one would be most unhappy to deal with the potential problems. Any abdominal procedure is serious, and an appendectomy can be simple or complicated. You don’t always know in advance what you will encounter. Mainly you need complete relaxation of the abdominal musculature, which is not under voluntary control.

          In general, I agree that what can be done safely without general anesthesia should be. However, IV analgesia backup in the hands of a skilled anesthetist is often appreciated by both doctor and patient.

      2. Windriven says:

        Larry Ferachi, an orthopedic surgeon in Baton Rouge, fixed a really badly broken leg for me. Time came for him to remove 2 screws above my ankle so that the healing bone could grow without being constrained by the rod. Ferachi wanted to book an OR at the surgery center. Having a high tolerance for pain which he was already familiar with, he agreed to just do a local in his office and back the screws out. No big deal.

        So he does a skin wheal with one of the caines and goes off to get the wrench (at the time it was basically a T-handle allen wrench, maybe still is). He made the incisions and started fishing around for the screw head. As Dr. Hall related, no big deal – more pressure than outright pain. So he fishes and fishes and finally concludes that this is the wrong sized wrench. Unfortunately it was the only size he had at the office. So off one of the nurses goes to collect a wrench from the surgery center.

        Time passes. Ferachi is off doing doctor stuff. I’m aware of the time passing. The lidocaine or whatever is also aware of the passing time. The nurse gets back, Ferachi comes in and starts digging with the new wrench. The lidocaine hadn’t abandoned me entirely but it was definitely headed toward Miller time. I didn’t say a word or make a sound. But I felt – quite viscerally – every turn of each of the screws. It was … unpleasant.

        So … the likelihood is that you can talk your anesthesiologist into whatever your preference is unless there is a really good reason not to – which the anesthesiologist will explain in detail.

        But be careful what you ask for.

        1. Frederick says:

          Allen screws in you leg hum? This is conclusive proof that you are indeed a Sentient alien robot, sent by the tall white ( or the lizards) to be a big pharma shill. Yep, CQFD ;-)

          1. Windriven says:

            You have the alien part right. Some would quibble about sentient.

      3. Calli Arcale says:

        I had upper endoscopy without the sedation, and while unpleasant, I think not being all goofy afterwards was worth enduring that short term discomfort. Also, I was able to actually remember the stuff the gastroenterologist told me afterwards, which is a bit of a problem with the sedation. Alas, I didn’t get to drive myself home, which was the main reason I’d wanted to skip the sedative, because they didn’t believe I could put up with it and even inserted a line to inject the sedative during the procedure if I couldn’t put up with it. They expressed skepticism before, which I found a bit insulting but I suppose somewhat helpful in that it made me want to prove myself. They were impressed afterwards. Apparently they’d never had anyone else refuse the sedative. *shrugs* I hate being groggy.

        I had my second child born by c-section under spinal block. It was wonderful. Completely aware of everything going on, no grogginess afterwards, and no pain at all. My grandfather had a total knee replacement that way too, because his previous experience with general anesthesia had been . . . bad. Well, the surgery had gone okay, but when he woke up he was back in WWII and tried to attack a nurse, thinking he’d fallen into the clutches of the Nazis. So a conscious procedure was best for all concerned.

        1. n brownlee says:

          Oh, Calli, you’re my ‘scope hero. I’ve had several colonoscopies without sedation, but anybody wants to cram a ‘scope down my throat will have to hold me down while heavy duty sedation takes hold. Blind panic will ensue.

        2. mouse says:

          Gosh – It never even occurred to me to have my endoscopy without sedation. I try to avoid discomfort when possible and I REALLY don’t like the idea of a tube down my throat. I guess I don’t mind the goofiness/spaciness of sedation. It’s not that different from my normal state. ;) I did have a drop in blood pressure after my endoscopy that made me a bit wobbly. But I also had a drop in blood pressure/wobbliness with the cervical steroid injections that I had without sedation*, so I suspect more a general response to procedures than a response to sedation.

          *The doctor who does the epidural injections requires an IV be placed before the procedure in case the patient needs sedation mid-procedure. I think that’s a reasonable precaution.

  11. Alia says:

    My mother had surgery on her varicose veins with only local anesthesia. And as a retired nurse, she was by no means spooked by the procedure, she spent most of the time chatting with one of the nurses. On the whole, she remembers the procedure as one of the easiest she had in her life.

  12. Spoony Quine says:

    You assume that hypno-anesthesia blocks pain via endorphins, but it doesn’t. It blocks pain the same way that conversion disorder causes a disability such as blindness, through dissociation.

    I had real numbness from conversion disorder for NINE YEARS. It was not an endorphin rush, trust me!

    Hypnosis helped me to reverse this dissociation and become aware of my body once again.

    You don’t know enough about hypnosis to make these claims. Luckily, I will be at TAM and can probably show you how to do it yourself!

  13. Spoony Quine says:

    Also, I would not claim that “trance” is anything but a deep type of meditation — it is dissociation!

    Interestingly, “trance” is not REQUIRED for hypnosis to work.

    You clearly do not understand how hypnosis works. Since I’ve just hypnotized an actual hypnotist for 15 minutes, I consider myself a real hypnotist now. He’s really hard to hypnotize!

    I could go on, but we can have some fun at TAM, ok? ;-) Then maybe you could write about THAT?

  14. Aaron Wright says:

    As usual, excellent write up separating facts from nonsense. I was disappointed when I heard this story on BBC Radio and they mentioned hypnosis. I actually planned on writing to the SGU to see what you all thought of this story. Guess I don’t have to now.

    I do have a question regarding hypnosis during surgery not as a pain management tool, but to help control blood pressure. I did a quick search regarding blood pressure during surgery, and from what I can find, I get the impression that doctors like to lower your blood pressure before starting surgery if possible to help prevent complications. If this is true, then could hypnosis be useful in keeping the blood pressure low during the surgery, thus preventing complications? Or is that even necessary with current drugs? I’d love to hear your thoughts on this. Thanks.

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