REPORT

“My voice goes with you”

© Laurence Buelens
© Laurence Buelens
Christine Watremez (left) and Fabienne Roelants, two of four specialists from the Hôpital Saint-Luc (Brussels), both trained in hypno-anaesthesia. © Laurence Buelens
Christine Watremez (left) and Fabienne Roelants, two of four specialists from the Hôpital Saint-Luc (Brussels), both trained in hypno-anaesthesia.
© Laurence Buelens

Operation being carried out under hypnosis at the Hôpital Saint-Luc. Anaesthesist Dr Christine Watremez (above) and surgeon Dr Parla Astarci and surgical instruments nurse Rosie Enonyi (left). © Laurence Buelens
© Laurence Buelens
Operation being carried out under hypnosis at the Hôpital Saint-Luc. Anaesthesist Dr Christine Watremez (above) and surgeon Dr Parla Astarci and surgical instruments nurse Rosie Enonyi (left). © Laurence Buelens
Operation being carried out under hypnosis at the Hôpital Saint-Luc. Anaesthesist Dr Christine Watremez (above) and surgeon Dr Parla Astarci and surgical instruments nurse Rosie Enonyi (left).
© Laurence Buelens.
Clamping and opening the artery to perform endarterectomy (removal of atherosclerotic plaque that causes narrowing of the vessel). © Laurence Buelens
Clamping and opening the artery to perform endarterectomy (removal of atherosclerotic plaque that causes narrowing of the vessel).
© Laurence Buelens
The patient, back in his room, with nurse Sophie Mertz, Dr Parla Astarci and Dr Christine Watremez (left to right). © Laurence Buelens
The patient, back in his room, with nurse Sophie Mertz, Dr Parla Astarci and Dr Christine Watremez (left to right).
© Laurence Buelens

Queen Fabiola of Belgium greatly helped to publicise the use of hypnosis in anaesthesia by undergoing this form of treatment herself in 2009. Developed at the University Hospital of Liège (BE), this practice has been copied in France, Switzerland and the United States, but Belgium remains the pioneer. We sent our reporter to the Cliniques Universitaires Saint-Luc in Brussels, where we watched carotid artery surgery being done under hypnosis.

You are driving your car. Suddenly, you realise how far you have driven, but that all this time your mind was elsewhere. This extremely common condition is nothing other than a mild hypnotic trance. That is, a state of consciousness, a different perception of the world, in which the unconscious comes to the surface.

“You need to be very careful with your use of words. The unconscious cannot handle negatives: if you ask the patient if he is not scared or if he is not afraid of pain, all he will remember are the words ‘scared’, ‘fear’ and ‘pain’, all of which are negatively connotated. This can derail the whole process”, warns Christine Watremez, an anaesthetist at Saint-Luc, before we met Jean, who is about to undergo an endarterectomy(1) for carotid stenosis.

We are far from such words when, on the eve of his surgery, we ask this pleasant retired gentleman in what state of mind he is in: “Calm, relaxed… I’m really surprised at myself! I’ve already had several operations under general anaesthesia and it’s never agreed with me. When they told me we could avoid this by operating under hypnosis, I jumped at the opportunity.

They have been practising hypno-anaesthesia for six years now at Saint-Luc. Apart from Christine Watremez, the clinic has three other anaesthetists trained in this technique. They carry out an average of two operations a day under hypnosis. One of them, Fabienne Roelants, tells us that patients are classified into four categories: “there are people like this patient who react badly to a general anaesthetic, there are self-employed people who want to return to work faster, and then there are a number of people who are referred to us because nobody dares to give them an anaesthetic because they are too fragile. And finally there are those who are just plain curious!”

Avoiding pharmacological coma

A general anaesthetic consists, no more nor less, of plunging the patient into a pharmacologically reversible coma, during which his respiratory and cardiac functions are performed by medical devices. This coma is induced by a cocktail of sedatives, causing loss of consciousness, painkillers, which suppress pain, and possibly of curare, which relaxes the muscles. It remains, therefore, a heavy and difficult to control medical act.

Hypnosis, which can be defined as a subjective state in which changes in perception can be induced by suggestion, has long been known to have an analgesic effect. It appeared in effect as an adjunct to surgery as early as 1830, but quickly fell into obscurity, eclipsed by the arrival of ether a few years later.

In 1992, Marie-Elisabeth Faymonville, an anaesthetist at the University Hospital of Liège (BE), became interested in work being done in Switzerland by an anaesthetist who was using hypnosis to relieve patients with severe burns. “I discovered that hypnosis was not a gift, but something that could be learned. I said to myself: we can develop this into a complete anaesthetic technique”, she recalls. That year, she popularised the practice with first aesthetic, then endocrine surgery. “Today, it is also being used in breast, vascular, ophthalmic and ear, nose and throat surgery. You can also use it for removing peripheral tumours or operating hernias”, she adds. In summary, we can say that the practice is suitable for all superficial surgery where a local anaesthesia is feasible but not enough to ensure patient comfort.

To date, the CHU Liège operating team has conducted more than 7 000 operations under hypnosis. Several clinical studies have assessed the effects. A retrospective study has examined nearly 200 thyroidectomy and 21 cervical explorations for hyperparathyroidism performed under hypno-sedation in Liège between 1994 and 1997. All patients reported a ‘pleasant experience’. Compared to a similar population operated under a general anaesthetic, postoperative pain was less, the use of analgesics reduced, patients’ recovery was significantly better, and their return to social and professional life was faster(2). Another study conducted in Boston and published in The Lancet in April 2000(3) also showed the cost, frequency of complications and duration of surgical interventions to be lower with hypnosis patients.

Marie-Elisabeth Faymonville also put together an international training programme in Liège. This has been taken so far by 450 anaesthetists, including Swiss, Luxembourg and Canadian practitioners, but especially large numbers of French. France too has a major training centre at Rennes. Germany and Austria are also beginning to show interest in the practice.

Hypno-sedation or hypno-analgesia?

When hypno-anaesthesia is used, sedation is either removed, in which case we talk of hypno-analgesia, or significantly reduced, in which case we talk of hypno-sedation. In Liège it is the latter that is practised, in Brussels they have preferred hypno-analgesia over the past several years. “We do not want to interfere with the hypnotic process by using a sedative. If the patient is comfortable, it is not necessary”, says Christine Watremez.

The next day, our patient will therefore receive only analgesics: a local product to desensitise the zone to be operated on and a light morphine derivative that the anaesthetist will dose as a function of the patient’s needs. “In fact we often reduce the dose, and at times we even stop the pump”, Christine Watremez explains. And it is in Sicily that Jean will allow his mind to wander. “During the preoperative consultation, I explained what hypnosis is, telling him that he would not sleep and would remain conscious. I told him he could change his mind whenever he wanted. Whether for surgical reasons or because the patient asks for it, we need to be able to switch to a general anaesthetic at any time. All our equipment is ready and waiting for this, and the monitoring task is exactly the same.” Jean had just one small job to do: finding a pleasant memory he wanted to relive. This would be his golden wedding, in the country of Bellini.

The transfigured operating theatre

“Can you hear, there, behind you? We can already hear your heart. There will be other noises as well, doors opening, perhaps people coming in or going out, talking… And then there will be the smells… the normal smells of a hospital. All these little things that are part of our daily lives, and which will be part of your environment during the coming hours. Here, the first infusion is in place, and we will now introduce the second, as I explained to you. And once this is done, we will get ready to start your journey. So off for a little trip to Sicily, right? You can change along the way in any case. I'll stay here beside you. OK like that?” Once Jean has been brought into the operating theatre, Christine Watremez takes charge of him. She will make sure he is totally familiar with the place, so that there is nothing to distract him during the hypnosis. This is also why the surgeon has explained the different movements he will be making. It is important that nothing surprise the patient.

About five minutes before the rest of the team arrives, the anaesthetist positions herself on a small stool near her patient’s ear and puts his hand in hers. To the rhythm of Jean’s breathing, her voice becomes softer, slower, more monotonous. “You’re going to fix your attention on a point in the ceiling. At the same time, you’re going to concentrate on each part of your body… And each time you breathe out, your body will relax… Allow the pleasant images of your journey to come up… Take a deep breath and let your mind wander off gently on this enjoyable and comfortable journey. Very good…” A wonderful calm invades the operating theatre. Surgeon Parla Astarci enters without a word, gives everyone a welcoming glance and begins to swab the area to be operated on with iso-betadine. Jean is already well away.

Adapting the surgeon’s movements

At times he opens his eyes, mumbles a few words, grasps the anaesthetist’s hands, or seems deeply asleep. And what if it does not work? “If the patient is motivated, ready to cooperate and we have his trust, it will work!”, comes Fabienne Roelants’ and Christine Watremez’s unhesitating response. In six years they have never had a single failure.

Apart from Christine Watremez, everybody keeps silent, except for a few whispers here and there. Occasionally, the anaesthetist gets up to sees how things are going from the other side of the operating table. Here too, practice has totally changed.

“You need to act like a musician playing a masterpiece”, is the immediate reaction from endocrine specialist Michel Mourad, who was the first to operate on patients under hypnosis at Saint-Luc. “The patient remains awake in our hands. He feels and experiences our movements. He reads our emotions. This imposes strict rules on us”, he explains.

Some general rules first of all: “the surgeon needs to avoid any tugging and to be gentle in his movements. Today we have new coagulation and sectioning tools which allow us to reduce the number of movements and noisy changes of instruments. Then there is the necessary self-control. “If bleeding occurs during surgery, I must remain cool. Otherwise the patient will sense my stress and become anxious. We need to possess the technical expertise to overcome any difficulties calmly. Which is why it seems to me that you need a certain experience on the job before launching into hypno-anaesthesia.”

On waking

The anaesthetist has been talking to Jean in this special voice throughout the operation. Once the wound has been sutured, she resumes her normal voice and says: “There you are, sir, the surgery is finished!” He opens his eyes and thanks her warmly. “It’s very rare that patients thank us after a traditional anaesthetic. With hypno-anaesthesia, they do so every time”, Christine Watremez tells us. “They’re surprised at the experience but happy at having gone through it. Above all, they realise that you can’t just make them do anything you want, and they’re not being manipulated. A few moments later, Jean is sitting up in bed and asking Parla Astarci: “Say doctor, as the left one [carotid, editor's note] went so well, possibly you could operate my right one as well?” A successful landing.

In the recovery room, he confides: “I’m pleasantly surprised. I didn’t expect it to be as comfortable, as easy. I was thinking all the time of Sicily, as if I was there. Did he feel anything?” Two or three pricks, but quite bearable. He finds it hard to put his experience into words, other than to express the conviction: “I was conscious, but I was elsewhere.”

Laurence Buelens

  1. Endarterectomy involves removing the atheroma plaque associated with excess cholesterol that clogs the internal carotid artery, and then suturing and enlarging it in order to avoid a stroke.
  2. Hypnoanesthesia for endocrine cervical surgery: a statement of practice”, T. Defechereux, M. Meurisse, E. Hamoir, L. Gollogly, J. Joris, M.-E. Faymonville, J Altern,Complement Med. 1999 Dec, 5(6):509-20.
  3. “Adjunctive non pharmacological analgesia for invasive medical procedures: A randomised trial”, E. Lang et al., Lancet 2000, 355:1486-90.

TOP

Read more

The mechanisms of hypnotic antalgia

Modern imaging techniques such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) have made it possible to objectify the effects observed in patients operated under hypno-anaesthesia.

When the body receives a painful stimulus, brain activity differs significantly depending on whether one is under hypnosis or in a normal waking state. The anterior cingulate cortex (ACC), which is credited, among other things, with cognitive functions such as reward anticipation, decision-making, empathy and emotion, seems to play a leading role during hypnosis. During it we observe an activation of the middle part of the ACC and changes in connectivity between it and the cortical and subcortical regions.

This particular brain activity would appear to permit a better encoding of nociceptive (= painrelated) information, and ultimately to respond more appropriately to it. According to some researchers, hypnosis prevents information from reaching the higher cortical regions which are responsible for the perception of pain. Others argue that it permits a better response, by more effectively activating the downward paininhibiting paths. Which neurotransmitters are involved in these activities remains, however, unknown.


TOP

Self-consciousness, a vast field of research

When all’s said and done, we know pretty little about how a general anaesthetic affects the body. It works well with some people and not with others. How do we explain this variability? What is taking place at the cell and gene level?

It is because she did not have all the answers to these questions that Marie-Elisabeth Faymonville developed hypno-anaesthesia techniques in 1992, and today is undertaking research into cognition. “What we do know is that vulnerable individuals can experience cognitive disturbances after general anaesthesia. We also know that the working memory – the one that allows us to retain credit card codes for example – is less disturbed after surgery under hypnosis”, she tells us.

“We would like to continue our research into the structures of self-consciousness using functional MRI. To assess the repercussions of the abolition of consciousness after a general anaesthetic and after hypno-sedation. How is cognition altered? Does this affect ageing? It would be wonderful to put together such a project.”

Post-operative research of this type is, however, very difficult to organise because we have to motivate patients to come back and take part in tests after their surgery. Another far from negligible methodological obstacle is that the active patient participation required in hypnosis rules out using randomised, double blind studies.


TOP