Anaesthetic Considerations for Recurrent Ventral Hernia Repair in a High-Risk 77-Year-Old Female

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Introduction

Recurrent ventral hernia surgery presents significant perioperative challenges, particularly in elderly patients with multiple systemic comorbidities. Factors such as obesity, diabetes, obstructive sleep apnea (OSA), moderate mitral stenosis, borderline renal function, and anticoagulation therapy considerably increase perioperative risk.

Anesthetic planning must therefore focus on meticulous preoperative optimization, vigilant intraoperative monitoring, hemodynamic stability, and safe postoperative recovery strategies. This case highlights the anesthetic management of a 77-year-old female undergoing elective recurrent ventral hernia repair under general anesthesia using rocuronium, remifentanil for induction, and reversal with sugammadex.

Case Illustration

A 77-year-old woman was posted for open repair of a recurrent ventral hernia.

Relevant Medical History

Diabetes mellitus
Systemic hypertension
Obesity (BMI 32)
Obstructive sleep apnea on regular BiPAP at home
Renal artery stenting done 10 years ago; borderline renal function tests
Anticoagulant therapy (rivaroxaban)
Moderate anemia (Hb 6 g/dL)
Poor effort tolerance (NYHA Class III)
Moderate mitral stenosis
- Mitral valve area: 1 cm²
- Mean gradient: 8–10 mmHg
- Pulmonary pressures: mildly elevated

Preoperative Workup

Airway: Mallampati III, restricted neck mobility
ECG: Sinus rhythm
Echocardiography: Preserved LV function, moderate MS
Renal profile: eGFR borderline (~40ml/min/1.73 m²)
Coagulation: Anticoagulation withheld 48 hours prior as per cardiology advice
OSA risk: STOP-BANG low

The patient was optimized with:

Control of blood sugars
Antihypertensives
Correction of hydration status
Packed RBC reserved
BiPAP night before surgery

She was deemed ASA Physical Status III–IV.

Anaesthetic Technique

MONITORING

Standard ASA monitors
Invasive arterial blood pressure line
ECG
Temperature and urine output
Capnography and agent monitoring

Given the cardiac lesion (moderate MS), goals included:

Avoid tachycardia
Maintain sinus rhythm
Prevent fluid overload
Avoid sudden drops in SVR

Induction

Remifentanil induction 150mcg, Remifentanil infusion (0.1–0.2 mcg/kg/min) throughout the surgery
Etomidate 2 mg/kg (preferred for hemodynamic stability)
Rocuronium 9 mg/kg for intubation

Intubation was done with video laryngoscopy with limited neck extension was smooth, avoiding sympathetic surges.

Maintenance

Desflurane in air–oxygen mixture
Remifentanil titrated for analgesia
Ventilation adjusted to avoid hypercarbia, which could worsen pulmonary pressures in MS
Balanced fluid strategy, avoiding overload
Phenylephrine/noradrenaline prepared for hypotension
Close watch on renal function: minimal nephrotoxic exposure

Intraoperative Course

Surgery lasted 2 hours 45 minutes. Estimated blood loss: ~100ml

Fluids administered: 1000ml crystalloid. Urine output: Adequate.

Hemodynamics remained stable with cautious titration of anesthetic agents and avoidance of tachycardia.

Emergence

Remifentanil tapered gradually
Neuromuscular blockade reversed using Sugammadex 2 mg/kg
Extubation performed in a semi-upright position, ensuring full wakefulness given severe OSA
Patient shifted to icu considering her age and multiple comorbidities
Application of BiPAP after the patient is shifted to icu

Postoperative Management

Respiratory Concerns (OSA)

Early application of bipap
Supplemental oxygen with continuous pulse oximetry
Monitoring for CO₂ retention

Cardiac Monitoring (Mitral Stenosis)

Avoid tachyarrhythmias
Maintain preload without volume overload
Beta-blocker continuation

Analgesia

Multimodal approach
IV paracetamol + low-dose opioids
Avoid excessive narcotics due to high OSA risk

Renal Protection

Monitor urine output
Avoid NSAIDs
Adjust antibiotic doses

Anticoagulation

Rivaroxaban restarted 24–48 hours postoperatively as per cardio-surgical plan No immediate complications were noted.