Deconditioned, large hernia

Gabrielle Morris

51yo lady with a large incisional hernia from her previous caesarean sections.

Background

  • Asthma with 1 previous hospitalisation but recently well controlled
  • Obesity BMI 38
  • Hip/back pain
  • Likely undiagnosed
  • Ex-smoker (low PYH)

Issues

  • Undifferentiated SOB
    • 20m on the flat, DASI 5 METS
  • Surgeon would like patient to lose weight preoperatively, suggested prehabilitation
  • Referred for CPET
    • AT 14ml/kg/min, peak VO2 16ml/kg/min
    • Formal lung function testing normal (nil e/o asthma/COPD)

Discussion

  • Was ordering the CPET test appropriate?
    • Expensive resource
    • Indications include:
      • Major open surgery
      • Undifferentiated SOB
      • Intermediate surgery to provide assistance with risk stratification, discussions about invasiveness or appropriateness of surgery, and to determine postoperative level of care.
    • Thought that in this instance it may help to determine the cause of her SOB (now thought to be deconditioning) and to provide a guide for prehabilitation targets. CPET is not necessarily needed to guide prehabilitation.
  • Plan from here?
    • While this patient is not considered high risk for surgery based on the CPET results, she could still be optimised in terms of fitness and weight reduction before this elective procedure

Plan

  • Discuss the plan and goals with the surgeon
    • Surgeon said this is a wide-necked hernia with a low risk of incarceration or strangulation and so agreed to a delay of 8wks to optimise the patient’s weight and fitness.
  • Referred for prehabilitation
    • The Kaden Centre is still offering home-based exercise programs which is ideal for this patient who lives at a distance. She is motivated to improve her fitness and has already lost 7kg in the last 2 months so is likely to do well with a program with limited supervision.
  • CPET results will be forwarded to the GP, including the formal lung function studies, to guide them in future asthma-medication prescribing (which may not be indicated for this patient).