Exploratory Laparotomy With Enhanced Recovery Under Combined Thoracic Segmental Spinal and Epidural Anesthesia in a...

Incisional hernia after an abdominal surgery may be complicated by small bowel obstruction (SBO), which needs prompt surgical intervention, commonly under general anesthesia (GA). Elderly patients with comorbidities are at high risk for anesthesia. Thoracic segmental spinal anesthesia (TSSA) is a feasible alternative in such high-risk cases where extended anesthesia duration may be achieved by combining epidural. We report the case of a 66-year-old obese female patient presenting with a three-day history of SBO with starvation ketosis and bilateral pleural effusion who underwent exploratory laparotomy under TSSA at T10 combined with epidural anesthesia at T11. The 4-hour procedure, involving 500 mL blood loss replaced with one unit of packed red blood cells, was successfully completed with stable vitals. The hypotension following TSSA responded to a bolus of 6 mg of ephedrine, and low-dose noradrenaline infusion was used to counteract further hemodynamic instability. The patient remained pain-free postoperatively, and noradrenaline was discontinued. Postoperative ketone levels normalized with early mobilization and enhanced recovery. This case report emphasizes that combined thoracic segmental spinal and epidural anesthesia can be used safely in managing complex high-risk surgical cases with a tailored anesthetic technique. Further studies with large samples are required to validate these findings.