Umbilical hernia, critical resp dx

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


  • 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


  • 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 


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


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