Anesthesia & Critical Care: Open Access

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Received: January 01, 1970 | Published: ,

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Letter to editor

In comparison with general anaesthesia, numerous studies have found that combined anaesthesia provides better analgesic quality and presents fewer cases of postoperative respiratory failure.¹ The use of combined general and epidural anaesthesia is well understood and commonly applied. This approach decreases anaesthetic requirements, makes it possible to carry out a postoperative analgesic strategy, can lower the blood loss and reduces postoperative complications such as respiratory failure and thrombosis.^2,3 Therefore, it is particularly indicated for obese patients undergoing surgical interventions, especially if a high rate of postoperative pain is to be expected.⁴

A good example of this situation is the patient who was treated at our hospital for a giant post-laparotomy hernia (Figures 1 & 2). This man, aged 52 years, had a clinical history of morbid obesity, obstructive sleep apnoea and intervention for appendicitis. Evaluation by the Mallampati test II revealed no predictor of difficult airway. An epidural catheter was inserted in the L2-L3 space, for Intraoperative analgesia. Small and large bowel loops were released from the hernia sac and reintroduced into the cavity. The bowel wall was then repaired by closing the sac flaps and inserting a mesh (Figures 3 & 4). Postoperative pain was controlled by an epidural infusion of ropivacaine plus fentanyl and rescue non steroidal anti-inflammatory drugs (NSAIDs). The patient reported good pain control and at 48 hours post-surgery the catheter was removed. The postoperative course was satisfactory and the patient was discharged from hospital after five days without incident of note.

Figure 1 Giant post-laparotomy hernia.

Figure 2 Giant post-laparotomy hernia.

Figure 3 Bowel wall repaired by closing the sac flaps and inserting a mesh.

Figure 4 Final outcome.

Given the patient’s background of obesity and respiratory problems, and the large size of the hernia and the possible duration of the intervention, we decided to apply combined anaesthesia, and thus obtain the advantages of epidural analgesia, i.e., less bleeding, better pain control, lower incidence of thrombotic events and fewer respiratory problems, among others.

Conclusion

We believe that for obese patients undergoing significant interventions, especially if they have respiratory problems or present a high risk of thrombosis, combined analgesia would be indicated (if anaesthesiologist has enough experience), thus improving comfort and reducing postoperative risks.