{"id":10766,"date":"2025-12-09T11:36:22","date_gmt":"2025-12-09T11:36:22","guid":{"rendered":"https:\/\/www.kauveryhospital.com\/ima-journal\/?p=10766"},"modified":"2025-12-15T08:19:20","modified_gmt":"2025-12-15T08:19:20","slug":"anaesthetic-considerations-for-recurrent-ventral-hernia-repair-in-a-high-risk-77-year-old-female","status":"publish","type":"post","link":"https:\/\/www.kauveryhospital.com\/ima-journal\/ima-journal-december-2025\/anaesthetic-considerations-for-recurrent-ventral-hernia-repair-in-a-high-risk-77-year-old-female\/","title":{"rendered":"Anaesthetic Considerations for Recurrent Ventral Hernia Repair in a High-Risk 77-Year-Old Female"},"content":{"rendered":"<p class=\"caps\">[vc_section][vc_row][vc_column][vc_column_text]<\/p>\n<h2>Introduction<\/h2>\n<p>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.<\/p>\n<p>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 <strong>77-year-old female <\/strong>undergoing elective recurrent ventral hernia repair under general anesthesia using <strong>rocuronium<\/strong>, <strong>remifentanil <\/strong>for induction, and reversal with <strong>sugammadex<\/strong>.<\/p>\n<h2>Case Illustration<\/h2>\n<p>A 77-year-old woman was posted for open repair of a recurrent ventral hernia.<\/p>\n<h2>Relevant Medical History<\/h2>\n<ul class=\"list\">\n<li><strong>Diabetes mellitus<\/strong><\/li>\n<li><strong>Systemic hypertension<\/strong><\/li>\n<li><strong>Obesity <\/strong>(BMI 32)<\/li>\n<li><strong>Obstructive sleep apnea <\/strong>on regular <strong>BiPAP at home<\/strong><\/li>\n<li><strong>Renal artery stenting <\/strong>done 10 years ago; <strong>borderline renal function tests<\/strong><\/li>\n<li><strong>Anticoagulant therapy <\/strong>(rivaroxaban)<\/li>\n<li><strong>Moderate anemia <\/strong>(Hb 6 g\/dL)<\/li>\n<li><strong>Poor effort tolerance <\/strong>(NYHA Class III)<\/li>\n<li><strong>Moderate mitral stenosis<\/strong>\n<ul class=\"list\" style=\"margin-top: 15px;\">\n<li>Mitral valve area: <strong>1 cm\u00b2<\/strong><\/li>\n<li>Mean gradient: <strong>8\u201310 mmHg<\/strong><\/li>\n<li>Pulmonary pressures: mildly elevated<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h2>Preoperative Workup<\/h2>\n<ul class=\"list\">\n<li><strong>Airway:<\/strong> Mallampati III, restricted neck mobility<\/li>\n<li><strong>ECG:<\/strong> Sinus rhythm<\/li>\n<li><strong>Echocardiography:<\/strong> Preserved LV function, moderate MS<\/li>\n<li><strong>Renal profile:<\/strong> eGFR borderline (~40ml\/min\/1.73 m\u00b2)<\/li>\n<li><strong>Coagulation:<\/strong> Anticoagulation withheld 48 hours prior as per cardiology advice<\/li>\n<li><strong>OSA risk:<\/strong> STOP-BANG low<\/li>\n<\/ul>\n<p>The patient was optimized with:<\/p>\n<ul class=\"list\">\n<li>Control of blood sugars<\/li>\n<li>Antihypertensives<\/li>\n<li>Correction of hydration status<\/li>\n<li>Packed RBC reserved<\/li>\n<li>BiPAP night before surgery<\/li>\n<\/ul>\n<p>She was deemed ASA Physical Status <strong>III\u2013IV<\/strong>.<\/p>\n<h2>Anaesthetic Technique<\/h2>\n<h2>MONITORING<\/h2>\n<ul class=\"list\">\n<li>Standard ASA monitors<\/li>\n<li>Invasive <strong>arterial blood pressure <\/strong>line<\/li>\n<li><strong>ECG<\/strong><\/li>\n<li><strong>Temperature <\/strong>and <strong>urine output<\/strong><\/li>\n<li><strong>Capnography <\/strong>and <strong>agent monitoring<\/strong><\/li>\n<\/ul>\n<p>Given the cardiac lesion (moderate MS), goals included:<\/p>\n<ul class=\"list\">\n<li>Avoid tachycardia<\/li>\n<li>Maintain sinus rhythm<\/li>\n<li>Prevent fluid overload<\/li>\n<li>Avoid sudden drops in SVR<\/li>\n<\/ul>\n<h2>Induction<\/h2>\n<ul class=\"list\">\n<li>Remifentanil induction 150mcg, Remifentanil infusion (0.1\u20130.2 mcg\/kg\/min) throughout the surgery<\/li>\n<li>Etomidate 2 mg\/kg (preferred for hemodynamic stability)<\/li>\n<li>Rocuronium 9 mg\/kg for intubation<\/li>\n<\/ul>\n<p>Intubation was done with video laryngoscopy with limited neck extension was smooth, avoiding sympathetic surges.<\/p>\n<h2>Maintenance<\/h2>\n<ul class=\"list\">\n<li>Desflurane in air\u2013oxygen mixture<\/li>\n<li>Remifentanil titrated for analgesia<\/li>\n<li>Ventilation adjusted to avoid hypercarbia, which could worsen pulmonary pressures in MS<\/li>\n<li>Balanced fluid strategy, avoiding overload<\/li>\n<li>Phenylephrine\/noradrenaline prepared for hypotension<\/li>\n<li>Close watch on renal function: minimal nephrotoxic exposure<\/li>\n<\/ul>\n<h2>Intraoperative Course<\/h2>\n<p>Surgery lasted <strong>2 hours 45 minutes<\/strong>. Estimated blood loss: <strong>~100ml<\/strong><\/p>\n<p>Fluids administered: <strong>1000ml crystalloid<\/strong>. Urine output: Adequate.<\/p>\n<p>Hemodynamics remained stable with cautious titration of anesthetic agents and avoidance of tachycardia.<\/p>\n<h2>Emergence<\/h2>\n<ul class=\"list\">\n<li>Remifentanil tapered gradually<\/li>\n<li>Neuromuscular blockade reversed using <strong>Sugammadex 2 mg\/kg<\/strong><\/li>\n<li>Extubation performed in a <strong>semi-upright position<\/strong>, ensuring full wakefulness given severe OSA<\/li>\n<li>Patient shifted to icu considering her age and multiple comorbidities<\/li>\n<li>Application of <strong>BiPAP <\/strong>after the patient is shifted to icu<\/li>\n<\/ul>\n<h2>Postoperative Management<\/h2>\n<h2>Respiratory Concerns (OSA)<\/h2>\n<ul class=\"list\">\n<li>Early application of bipap<\/li>\n<li>Supplemental oxygen with continuous pulse oximetry<\/li>\n<li>Monitoring for CO\u2082 retention<\/li>\n<\/ul>\n<h2>Cardiac Monitoring (Mitral Stenosis)<\/h2>\n<ul class=\"list\">\n<li>Avoid tachyarrhythmias<\/li>\n<li>Maintain preload without volume overload<\/li>\n<li>Beta-blocker continuation<\/li>\n<\/ul>\n<h2>Analgesia<\/h2>\n<ul class=\"list\">\n<li>Multimodal approach<\/li>\n<li>IV paracetamol + low-dose opioids<\/li>\n<li>Avoid excessive narcotics due to high OSA risk<\/li>\n<\/ul>\n<h2>Renal Protection<\/h2>\n<ul class=\"list\">\n<li>Monitor urine output<\/li>\n<li>Avoid NSAIDs<\/li>\n<li>Adjust antibiotic doses<\/li>\n<\/ul>\n<h2>Anticoagulation<\/h2>\n<ul class=\"list\">\n<li>Rivaroxaban restarted 24\u201348 hours postoperatively as per cardio-surgical plan No immediate complications were noted.<\/li>\n<\/ul>\n<h2>Anaesthetic Considerations<\/h2>\n<h2>1.\u00a0 Cardiovascular Management (Moderate Mitral Stenosis)<\/h2>\n<ul class=\"list\">\n<li>Maintain sinus rhythm<\/li>\n<li>Heart rate 50\u201370 bpm<\/li>\n<li>Avoid tachycardia, hypovolemia, or overhydration<\/li>\n<li>Prevent pulmonary congestion<\/li>\n<li>Gentle induction and emergence<\/li>\n<\/ul>\n<h2>2.\u00a0 Respiratory Concerns (Obesity + OSA)<\/h2>\n<ul class=\"list\">\n<li>Difficult ventilation risk<\/li>\n<li>Avoid sedative premedication<\/li>\n<li>Plan for awake extubation<\/li>\n<li>Ensure postoperative BiPAP use<\/li>\n<\/ul>\n<h2>3.\u00a0 Renal Function (Borderline)<\/h2>\n<ul class=\"list\">\n<li>Prefer renally safe drugs<\/li>\n<li>Maintain perfusion pressure<\/li>\n<li>Avoid nephrotoxins<\/li>\n<\/ul>\n<h2>4.\u00a0 Anticoagulation<\/h2>\n<ul class=\"list\">\n<li>Manage perioperative interruption based on thrombotic risk<\/li>\n<li>Assess bleeding vs clotting risk<\/li>\n<\/ul>\n<h2>5.\u00a0 Anemia<\/h2>\n<ul class=\"list\">\n<li>Optimization pre-op<\/li>\n<li>Prepare blood products<\/li>\n<li>Minimize blood loss<\/li>\n<\/ul>\n<h2>6.\u00a0 Neuromuscular Blockade Strategy<\/h2>\n<ul class=\"list\">\n<li>Rocuronium suitable in renal compromise<\/li>\n<li><strong>Sugammadex <\/strong>chosen for reliable reversal<\/li>\n<\/ul>\n<h2>Conclusion<\/h2>\n<p>Recurrent ventral hernia repair in an elderly patient with severe systemic comorbidities\u2014OSA, moderate mitral stenosis, renal impairment, obesity, anticoagulation therapy, and anemia\u2014requires careful preoperative optimization and a well-coordinated anesthetic plan.<\/p>\n<p>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\u2019s uneventful perioperative course.<\/p>\n<ol class=\"decimal\">\n<li>Walker RP, Durazo-Arvizu R, Wachte<a href=\"https:\/\/scholar.google.com\/scholar_lookup?journal=Laryngoscope&amp;title=Preoperative%20differences%20between%20male%20and%20female%20patients%20with%20sleep%20apnoea&amp;author=RP%20Walker&amp;author=R%20Durazo-Arvizu&amp;author=B%20Wachter&amp;author=C%20Gopalsami&amp;volume=111&amp;publication_year=2001&amp;pages=1501-5&amp;pmid=11568595&amp;doi=10.1097\/00005537-200109000-00001\">r B, Gopalsami<\/a> Preoperative differences between male and female patients with sleep apnoea. Laryngoscope. 2001;111:1501\u20135. Doi: 10.1097\/00005537-200109000-00001. [DOI] [PubMed] [Google Scholar]<\/li>\n<li>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.<\/li>\n<li>El\u2010Orbany M, Antapli The optimal dose of rocuronium for rapid sequence induction. Can J Anaesth. 2009;56:87<\/li>\n<li>Crawford MW, Hayes J, Tan JM. Dose\u2010response of remifentanil for tracheal intubation in Anesth Analg. 2005;100:1599\u20101604. [DOI] [PubMed] [Google Scholar]<\/li>\n<li>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\u201082. [PubMed]<\/li>\n<\/ol>\n<div class=\"row\" style=\"padding-top: 30px;\">\n<div class=\"col-md-2 col-sm-4 col-xs-4 paddingbottom\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-full wp-image-10225\" src=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2025\/05\/person-placeholder-female.jpg\" alt=\"\" width=\"700\" height=\"700\" srcset=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2025\/05\/person-placeholder-female.jpg 700w, https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2025\/05\/person-placeholder-female-300x300.jpg 300w, https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2025\/05\/person-placeholder-female-150x150.jpg 150w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/div>\n<div class=\"col-md-10 col-sm-8 col-xs-8 paddingbottom\">\n<p style=\"font-size: 15px;\" align=\"left\"><b>Dr. Umadevi, MBBS.,DA<br \/>\n<a href=\"https:\/\/www.kauveryhospital.com\/\">Kauvery Hospital, Chennai.<\/a><\/b><\/p>\n<\/div>\n<\/div>\n<div class=\"row\" style=\"padding-top: 30px;\">\n<div class=\"col-md-2 col-sm-4 col-xs-4 paddingbottom\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-full wp-image-6490\" src=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2023\/04\/Dr.-Hemalatha-Iyanar2021-07-08-10_34_06am.jpg\" alt=\"Dr. Hemalatha\" width=\"600\" height=\"703\" srcset=\"https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2023\/04\/Dr.-Hemalatha-Iyanar2021-07-08-10_34_06am.jpg 600w, https:\/\/www.kauveryhospital.com\/ima-journal\/wp-content\/uploads\/2023\/04\/Dr.-Hemalatha-Iyanar2021-07-08-10_34_06am-256x300.jpg 256w\" sizes=\"auto, (max-width: 600px) 100vw, 600px\" \/><\/div>\n<div class=\"col-md-10 col-sm-8 col-xs-8 paddingbottom\">\n<p style=\"font-size: 15px;\" align=\"left\"><b>Dr. Hemalatha<br \/>\nSenior Consultant, Anesthesiology,<br \/>\n<a href=\"https:\/\/www.kauveryhospital.com\/\">Kauvery Hospital, Chennai.<\/a><\/b><\/p>\n<\/div>\n<\/div>\n<p>[\/vc_column_text][\/vc_column][\/vc_row][\/vc_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>[vc_section][vc_row][vc_column][vc_column_text] 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,<\/p>\n","protected":false},"author":2,"featured_media":10767,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[95],"tags":[],"class_list":["post-10766","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ima-journal-december-2025"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.0 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Anaesthetic Considerations for Recurrent Ventral Hernia Repair in a High-Risk 77-Year-Old Female<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.kauveryhospital.com\/ima-journal\/ima-journal-december-2025\/anaesthetic-considerations-for-recurrent-ventral-hernia-repair-in-a-high-risk-77-year-old-female\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Anaesthetic Considerations for Recurrent Ventral Hernia Repair in a High-Risk 77-Year-Old Female\" \/>\n<meta property=\"og:description\" content=\"[vc_section][vc_row][vc_column][vc_column_text] Introduction Recurrent ventral hernia surgery presents significant perioperative challenges, particularly in elderly patients with multiple systemic comorbidities. 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