Anaesthetic Management of Laparoscopic Incisional Hernia Repair in a Patient with Myasthenia Gravis: Case Report

Myasthenia Gravis (MG) is an autoimmune disorder of the neuromuscular junction, often complicated by perioperative respiratory and neuromuscular challenges. Patients with MG undergoing laparoscopic incisional hernia repair pose unique peri-operative anaesthetic challenges due to muscle relaxants even in the periods of complete remission due to altered neuromuscular transmission, risk of respiratory compromise, and the physiological changes associated with pneumoperitoneum. A 66-year-old female patient with well-controlled MG on medications, who developed an incisional hernia following an open cholecystectomy performed five years prior, presented for laparoscopic surgical repair. Over the last three years, the hernia progressively enlarged, prompting surgical intervention. Preoperative optimisation included stable MG control with pyridostigmine. Intraoperative management featured careful titration of neuromuscular blockade, the use of remifentanil infusion for stable haemodynamics and precise analgesia control, selective opioid choice, and vigilant neuromuscular and respiratory monitoring. Ultrasound guided fascial plane block for intraoperative and postoperative analgesia to minimise systemic opioid requirements. The patient remained haemodynamically stable throughout the procedure, with adequate surgical conditions using low-dose non-depolarising muscle relaxants guided by train-of-four monitoring. The fascial plane block provided effective pain control, reducing the need for high-dose systemic opioids. The patient achieved early mobilisation and was discharged on postoperative day three without complications. This case illustrates that meticulous clinical assessment and planning, including an appropriate analgesic regimen with a fascial plane block, judicious use of short-acting opioids (remifentanil) intraoperatively, careful neuromuscular monitoring, and stable MG disease management, can lead to a successful laparoscopic incisional hernia repair with minimal complications in a patient with MG.