Ultrasound-Guided Intertransverse Process and Deep Rectus Sheath Blocks for Emergency Laparoscopic Cholecystectomy in...

Gangrenous cholecystitis with peritonitis in elderly, high-risk patients carries substantial perioperative risk, particularly when compounded by multiple comorbidities, coagulopathy, and sepsis. General anesthesia in such patients is associated with increased hemodynamic instability and postoperative morbidity. Regional anesthesia combined with procedural sedation has been proposed as a safer alternative in selected high-risk surgical candidates. We report the case of an 81-year-old woman who presented with cholecystitis complicated by diffuse peritonitis. Her medical history included cerebral ischemic stroke, diabetes mellitus, stage 3 chronic kidney disease, and arterial hypertension. On admission, she was septic, with elevated C-reactive protein (44 mg/L) and procalcitonin (10.9 ng/mL), hypoalbuminemia (2.5 g/dL), and a deranged coagulation profile (INR 1.9). Given the high anesthetic risk associated with general anesthesia, a regional strategy was adopted, combining an ultrasound-guided intertransverse process (ITP) block (T7-T8/T8-T9, ropivacaine 0.2%, 20 mL) with bilateral deep rectus sheath (DRS) blocks (ropivacaine 0.2%, 20 mL each side). Surgery began 30 minutes after block placement under sedation with dexmedetomidine (1 mcg/kg bolus followed by 1.2 mcg/kg/h infusion) and ketamine (0.25 mg/kg/h, total dose 40 mg). Laparoscopic cholecystectomy was completed in 90 minutes, with hemodynamics remaining stable throughout (mean arterial pressure approximately 65 mmHg). The patient emerged from the operating room sedated but breathing spontaneously, without the need for airway instrumentation, and was admitted to the intensive care unit for monitoring. She was discharged from the intensive care unit after 20 hours in stable condition and discharged home on postoperative day 8. Combined ultrasound-guided ITP and DRS blocks, supplemented with dexmedetomidine-ketamine sedation, provided effective anesthesia for emergency laparoscopic cholecystectomy while avoiding general anesthesia in an elderly, septic, high-risk patient with coagulopathy. This approach may represent a viable strategy to reduce perioperative risk in similarly frail surgical candidates.