Opioid-Free Anesthesia for Robot-Assisted Hysterectomy in Morbid Obesity

relevance: Patients with morbid obesity undergoing general anesthesia for laparoscopic surgery are highly sensitive to complications, including transient hypoxemia, hemodynamic instability, delayed awakening, opioid hypersensitivity, postoperative pulmonary complications, and postoperative nausea and vomiting. Optimization of anesthesia management without opioids remains an important clinical challenge.

CASE DESCRIPTION: A 35-year-old female patient (height 164 cm, weight 180 kg, body mass index 66.9 kg/m²) underwent robot-assisted hysterectomy for recurrent endometrial hyperplasia under combined anesthesia (general anesthesia with epidural analgesia).

The mean qCON (consciousness index) during surgery was 50.2. The analgesic component of anesthesia was achieved through epidural administration of 0.1% ropivacaine hydrochloride solution, 10 mL every 30 minutes, at an infusion rate of 250 mL/hour during bolus delivery. The mean qNOX (nociception index) was 29.8. The mean total duration of qNOX peaks was 98.2 seconds over the 2 hours 35 minutes of surgery. Intraoperative hemodynamics were stable: blood pressure ranged from 120/70 to 140/80 mm Hg, heart rate 70–80 bpm, and SpO₂ 98–100%. Muscle relaxation was not maintained by additional administration of rocuronium bromide due to adequate relaxation of the abdominal wall and absence of inspiratory triggering from the patient. The TOF neuromuscular transmission ratio ranged from 40% to 50%, and electromyography (EMG) values ranged from 10 to 25, indicating adequate relaxation of the anterior abdominal wall muscles. The postoperative period was uneventful. The patient was discharged on postoperative day 6 in satisfactory condition with no active complaints.

CONCLUSION: In this clinical case, the chosen anesthesia management tactic provided effective analgesia and enabled early mobilization of the patient.