Ultrasound-Guided Rectus Sheath Block With Monitored Anesthesia Care for Necrotic Umbilical Hernia Repair in a Patient With Severe Liver Failure and Refractory Ascites: A Case Report

Patients with severe liver dysfunction present significant perioperative challenges, including the risk of postoperative cognitive dysfunction (POCD) and hepatic encephalopathy (HE), after general anesthesia. While avoiding general anesthesia and deep sedation is crucial for early recovery in this patient population, neuraxial block techniques are often contraindicated due to coagulation disorders. A 73-year-old male patient (190 cm tall, weighing 77 kg) with Child-Pugh C cirrhosis (score 10), coagulopathy (platelets 90,000/μL, prothrombin time (PT) activity 47%), and complex medical history, including treated hepatocellular carcinoma, renal cancer, and bladder cancer, underwent necrotic umbilical hernia repair. The patient, classified as American Society of Anesthesiologists (ASA) physical status IV with a Model for End-Stage Liver Disease (MELD) score of 19, had been hospitalized for two months due to an umbilical hernia infection refractory to antibiotic therapy. After careful preoperative assessment, we selected monitored anesthesia care (MAC) as the preferred anesthetic approach due to the patient's high surgical risk. We performed a bilateral rectus sheath block (RSB) using diluted ropivacaine (0.15%, total 80 mL) with epinephrine (15 μg). Sedation was achieved using dexmedetomidine without a loading dose, supplemented with midazolam and low-dose remifentanil. This approach allowed us to maintain spontaneous breathing while providing adequate analgesia and patient comfort. The surgery was completed successfully with stable hemodynamics and respiratory functions. Throughout the procedure, hemodynamic parameters remained within 20% of baseline values, and bispectral index (BIS) values were maintained between 65 and 80, indicating appropriate sedation depth without excessive anesthetic administration. Ultrasound-guided RSB combined with carefully titrated MAC provides safe and effective anesthesia for umbilical hernia repair in patients with severe liver dysfunction. This approach maintains spontaneous breathing, delivers effective analgesia for somatic and visceral pain, and facilitates clearer differentiation between residual anesthetic effects and worsening HE postoperatively. When coagulopathy precludes neuraxial techniques, this pharmacokinetically informed strategy offers a valuable alternative for high-risk abdominal wall procedures.