SHORT CASE PRESENTATION

CASE SUMMARY

1. CASE PRESENTATION

• 45-year-old female
• Presents with a reducible/irreducible ventral hernia (likely incisional or primary epigastric/umbilical)
• Scheduled for elective hernia reduction and abdominal wall repair (open or laparoscopic)

• Duration of swelling and any prior abdominal surgeries (key for incisional hernia)
• Episodes of pain, nausea, or vomiting suggesting incarceration or obstruction
• Bowel habits - any constipation/straining (raised intraabdominal pressure)
• Comorbidities: obesity (BMI), diabetes mellitus, hypertension, COPD
• Menstrual and obstetric history
• Drug history, allergies, prior anaesthetic history

2. PHYSICAL EXAMINATION

• Build/BMI (obesity is a major risk factor for ventral hernia and complications)
• Pallor, edema, jaundice

• Site, size, shape of swelling
• Reducibility, cough impulse
• Skin over swelling (erythema suggests incarceration/strangulation)
• Bowel sounds

• Mouth opening, Mallampati grade, thyromental distance, neck movements
• Look for features of difficult airway (especially if obese)

3. INVESTIGATIONS

4. ANAESTHETIC CONCERNS

1. Difficult airway - if obese, restricted neck mobility
2. Aspiration risk - bowel obstruction if hernia is incarcerated; full stomach precautions
3. Raised intraabdominal pressure - post-repair, can impair diaphragmatic excursion and ventilation
4. Obesity - reduced FRC, prone to desaturation; OSA possible
5. Positioning - supine with possible head-up tilt
6. Haemodynamic instability - with large hernia contents being reduced, sudden return of bowel causes intraabdominal hypertension
7. Postoperative pain - major concern due to extensive abdominal wall repair; good analgesia mandatory
8. DVT risk - abdominal surgery + obesity + female sex

5. ANAESTHETIC MANAGEMENT

Preoperative

• Optimize comorbidities (DM, HTN)
• 6-hour fasting for solids, 2 hours for clear fluids
• Anxiolytic premedication: Tab. alprazolam 0.25 mg night before (or Tab. diazepam 5 mg)
• Antacid prophylaxis: Tab. ranitidine 150 mg (or PPI) the night before and morning of surgery
• DVT prophylaxis: LMWH (enoxaparin) and TED stockings

Choice of Anaesthesia

• Induction: Inj. Glycopyrrolate 0.2 mg IV, Inj. Fentanyl 2 mcg/kg IV, Inj. Propofol 1.5-2 mg/kg IV (or thiopentone 5 mg/kg)
• Intubation: Inj. Succinylcholine 1.5 mg/kg (RSI if bowel obstruction risk) or Inj. Vecuronium/Rocuronium
• Maintenance: O2 + N2O + Isoflurane/Sevoflurane + intermittent Vecuronium
• Muscle relaxation is essential for adequate working space and abdominal wall closure

• Spinal at L3-L4: Inj. Bupivacaine (H) 0.5% 3 mL + Inj. Fentanyl 25 mcg
• Level needed: T4 for upper abdominal, T6 for lower
• Epidural (with catheter) provides ongoing analgesia postoperatively

• Useful for prolonged surgeries + extended postoperative analgesia

Intraoperative Monitoring

• Pulse oximetry (SpO2)
• Non-invasive blood pressure (NIBP)
• ECG
• End-tidal CO2 (EtCO2)
• Temperature
• Urine output (IDC)
• Neuromuscular monitoring (TOF) if muscle relaxants used

Intraoperative Considerations

• IV access: two large-bore cannulas
• IV fluids: Ringer's Lactate as maintenance; guided by haemodynamic status
• Ventilation: volume-controlled, avoid high airway pressures post-repair
• Antibiotic prophylaxis: Inj. Cefazolin 1-2 g IV at induction

Postoperative Analgesia

• Multimodal analgesia:
  • Inj. Paracetamol 1g IV 8-hourly
  • Inj. Diclofenac 75 mg IV/IM 12-hourly (avoid if NSAID contraindicated)
  • Regional blocks: Transversus Abdominis Plane (TAP) block - bilateral TAP block with 0.25% bupivacaine 20 mL each side provides excellent abdominal wall analgesia
  • Erector Spinae Plane (ESP) block - alternative, opioid-sparing
  • Epidural infusion if catheter placed
  • Inj. Tramadol 100 mg IV as rescue analgesia

Reversal and Extubation

• Inj. Neostigmine 0.05 mg/kg + Inj. Glycopyrrolate 0.01 mg/kg IV
• Extubate awake, when neuromuscular blockade fully reversed (TOF ratio >0.9)
• Sit patient up after extubation (reduces diaphragm loading)

6. POSTOPERATIVE CARE

• High-dependency nursing (4-6 hours post-op)
• Continue IV fluids until oral intake resumes
• Early ambulation (reduces DVT risk)
• Respiratory physiotherapy - incentive spirometry
• Monitor for complications:
  • Wound hematoma / seroma
  • Ileus
  • Respiratory compromise (especially large repair)
  • Abdominal compartment syndrome (rare, large hernia)
  • Hernia recurrence

7. SUMMARY TABLE

1. TAP block is the regional technique of choice for abdominal wall surgery - it provides excellent somatic analgesia for the anterior abdominal wall.
2. Muscle relaxation is mandatory for good surgical conditions during abdominal wall repair.
3. Pneumoperitoneum during laparoscopic repair raises EtCO2 - increase minute ventilation by 10-20%.
4. Post-repair, increased intraabdominal pressure can restrict diaphragmatic movement - avoid premature extubation.
5. Multimodal analgesia with opioid-sparing techniques improves recovery and reduces PONV.