Consult – 83-year-old lady for consideration of umbilical hernia repair

Background

• Reducible umbilical hernia 
• Recent onset intermittent abdominal pain – 1 hospital admission
• CT during last admission revealed AAA with suspicion of leak
• EVAR performed under LA and fentanyl sedation 07/21. Uneventful.
• General surgical team reviewed in hospital and recommended elective repair of hernia

Issues

• Severe COPD – Home Oxygen 16 hours per day. 
• SpO2 94% on RA. FEV1=0.99, FVC=1.48. TLCP 37%
• Hospital admission 03/21 with infective exacerbation
• Steroid requirement post-EVAR
• DASI=3.9 METs
• NYHA class 3 dyspnoea. Walked approx. 200m on flat at clinic without stopping, profoundly dyspnoeic afterwards.
• Chronic renal impairment – stage 2, deteriorated post-EVAR 

Discussion

Should Surgery Proceed?

• Consensus was yes, recent longer procedure was tolerated well
• Preferable risk profile with elective repair rather than an emergency procedure for a strangulated hernia

Conduct of Anaesthesia

• Patient and surgeon very keen for regional anaesthesia
• Patient very well-informed, understands risks and keen to proceed
• Spinal discussed as an option – most felt it wouldn’t provide suitable analgesia for peritoneal component of surgery
• Options would be spinal or epidural with surgical infiltration to peritoneum or bilateral rectus sheath blocks (recommended option by local regional experts)
• Notably, the patient would be suitable for a short GA if required

Plan:

• Proceed with surgery
• Discuss meeting recommendations with procedural anaesthetist when allocated.