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

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.

Anaesthetic Considerations

1.  Cardiovascular Management (Moderate Mitral Stenosis)

• Maintain sinus rhythm
• Heart rate 50–70 bpm
• Avoid tachycardia, hypovolemia, or overhydration
• Prevent pulmonary congestion
• Gentle induction and emergence

2.  Respiratory Concerns (Obesity + OSA)

• Difficult ventilation risk
• Avoid sedative premedication
• Plan for awake extubation
• Ensure postoperative BiPAP use

3.  Renal Function (Borderline)

• Prefer renally safe drugs
• Maintain perfusion pressure
• Avoid nephrotoxins

4.  Anticoagulation

• Manage perioperative interruption based on thrombotic risk
• Assess bleeding vs clotting risk

5.  Anemia

• Optimization pre-op
• Prepare blood products
• Minimize blood loss

6.  Neuromuscular Blockade Strategy

• Rocuronium suitable in renal compromise
• Sugammadex chosen for reliable reversal

Conclusion

Recurrent ventral hernia repair in an elderly patient with severe systemic comorbidities—OSA, moderate mitral stenosis, renal impairment, obesity, anticoagulation therapy, and anemia—requires careful preoperative optimization and a well-coordinated anesthetic plan.

Using etomidate, remifentanil, and rocuronium provided smooth, hemodynamically stable induction, while extubation assisted by sugammadex and early postoperative BiPAP ensured safe respiratory recovery. Multidisciplinary collaboration and vigilant monitoring were essential to the patient’s uneventful perioperative course.

1. Walker RP, Durazo-Arvizu R, Wachter B, Gopalsami[1] Preoperative differences between male and female patients with sleep apnoea. Laryngoscope. 2001;111:1501–5. Doi: 10.1097/00005537-200109000-00001. [DOI] [PubMed] [Google Scholar]
2. El Sabbagh Abdallah, Reddy Yogesh V., Barros-Gomes Sergio, Borlaug Barry A., Miranda William R., Pislaru Sorin V., et al. Low-Gradient Severe Mitral Stenosis: Hemody- Namic Profiles, Clinical Characteristics, and Outcomes. J Am Heart Assoc. 2019 Mar 5;8(5):e010736.
3. El‐Orbany M, Antapli The optimal dose of rocuronium for rapid sequence induction. Can J Anaesth. 2009;56:87
4. Crawford MW, Hayes J, Tan JM. Dose‐response of remifentanil for tracheal intubation in Anesth Analg. 2005;100:1599‐1604. [DOI] [PubMed] [Google Scholar]
5. Das S, Forrest K, Howell S. General anaesthesia in elderly patients with cardiovascular disorders: choice of anaesthetic agent. Drugs Aging. 2010 Apr 01;27(4):265‐82. [PubMed]