A 53-year-old female, weighing 110 kg and height of 153 cm (body mass index (BMI) = 46.9 kg/m2), presented with paraumbilical swelling and a history of excessive snoring and dyspnea on exertion. On ultrasonography, she had a grade III fatty liver and a right-sided paraumbilical hernia. She was planned for laparoscopic mesh hernia repair. On pre-anesthetic evaluation besides the history of hypertension, she had excessive snoring and dyspnea during normal physical activity (breath holding time 15 s), however, denied frequent awakenings or breathlessness during sleep, and daytime somnolence. She used to resort to lateral decubitus most of the time. Her pulmonary function tests (FVC = 83%, FEV1 = 68%, FEV1/FVC = 87%) revealed moderate obstruction with no significant reversibility. Room air arterial blood gas analysis (ABG) showed SaO2 = 93%, PaO2 = 66, PaCO2 = 38 mmHg. Echocardiography revealed a normal study with ejection fraction = 60%. Chest X-ray and ECG showed no abnormalities and the rest of the blood investigations were within normal limits. The patient was planned for surgery after 1 week of optimization with auto-continuous positive airway pressure (CPAP), incentive spirometry, steam inhalation, and nebulization with bronchodilators.

Standard fasting guidelines were obeyed, and the patient was shifted to pre-anesthesia room, where all standard American Society of Anesthesiologist (ASA) monitors were attached and intravenous (IV) access was secured.

For QL block, the patient was positioned in the right lateral position, so that the pannus will shift forward, and a wedge was placed below the flank to increase the space between the iliac crest and coastal margin (Fig. 1a). A high-frequency (13–6 Hz) linear ultrasound (Sonosite Edge Bothell, WA, USA) probe was placed over the flank transversely. After identifying the layers of the anterior abdominal wall and QL, a 22-g 10-cm echogenic needle (Pajunk, Gesingein, Germany) was introduced in the plane to the probe after local skin infiltration with 2% lignocaine. The needle was then advanced further to place the tip anterolateral to the QL muscle. Once the fascia was popped the tip was confirmed with 1 ml saline following which 30 ml 0.375% ropivacaine was deposited. The drug could be seen spreading both anterior and posterior to the QL muscle (Fig. 1b).

a Patient positioned lateral and high-frequency probe placed transversely over the flanx. b Needle path and local anesthetic deposit anterolateral to quadratus lumborum (QL) muscle EOM—external oblique, IOM—internal oblique, TAM—transverse abdominis muscle, *****—local anesthetic

Once the block was performed patient was shifted to the operation table and positioned in the ramp position. The patient was pre-oxygenated and general anesthesia was induced with IV fentanyl 50 mcg, propofol 150 mg, and suxamethonium 200 mg. The airway was secured under direct laryngoscopic vision, using size 7.5 cuffed endotracheal tube and anesthesia was maintained with oxygen (50%), air, and desflurane (minimum alveolar concentration = 1). Neuromuscular blockade was maintained with atracurium boluses.

Intraoperatively one 12 mm and two 5 mm ports were made on the left lateral abdominal wall (Fig. 2a). Pneumoperitoneum was achieved and maintained at 15 cm H2O pressure. A 3 × 3 cm paraumbilical defect was seen and contents reduced completely, sealed with 15 × 15 cm proline mesh. The surgery lasted 40 min uneventfully with minimal blood loss. Vitals remained stable throughout the surgery and there was no requirement of rescue opioids intraoperatively. IV paracetamol 1 g and ondansetron 8 mg were administered before closure. Neuromuscular blockade was reversed with neostigmine and glycopyrrolate and the trachea was extubated after confirming the adequacy of consciousness, minute volume and regular breathing. Patient was awake, conscious, and pain free after extubation.

a Pneumoperitoneum with port insertion site and hernia location. b Patient lying comfortably in post-anesthesia care unit

Postoperatively, patient was quite comfortable, however, kept in a high dependency unit for observation and auto CPAP was applied in a propped-up position (Fig. 2b). IV paracetamol 1 gm was continued 6th hourly and pain was assessed by visual analog scale (VAS 0 being no pain 10 worst pain) at 30 min 2, 4, 6, 8, 12, 24 h. Around 12 h after surgery, she had VAS > 4 on straining, which was subsided by IV diclofenac 75 mg diluted in 100 ml normal saline. In 24 h, the average VAS was 3. The next day morning, patient was mobilized during which she complained of mild pain (VAS of 3). Thereafter, she was started on oral tablets of paracetamol which provided adequate analgesia to the patient during the follow-up period. There was no supplementary opioid rescue and no episode of vomiting.