Agathiyan Anbarasu, Anand Kuppusamy, N Mohammed Arshad
Perioperative management of extremely preterm neonates is challenging because of their immature respiratory, cardiovascular and metabolic systems, which make them highly vulnerable to perioperative instability. Hereby, the authors report the perioperative management of a 22‑day‑old male neonate, born at 27 weeks of gestation with a birth weight of 1.225 kg, who presented with an incarcerated right inguinoscrotal hernia at a post‑conceptional age of 30 weeks. His initial neonatal course was complicated by respiratory distress syndrome requiring mechanical ventilation and surfactant therapy, followed by Continuous Positive Airway Pressure (CPAP) and gradual weaning to room air. For herniotomy, the authors planned an individualised, opioid‑free multimodal anaesthetic technique to minimise the risk of postoperative apnoea. Intraoperative management focused on maintaining stable oxygenation, normothermia, normoglycaemia and haemodynamic stability in a very preterm neonate with limited physiological reserve. Intraoperatively, the authors encountered a rare finding of a perforated appendix within the hernial sac (Amyand’s hernia), for which appendectomy along with hernia repair was done. Ultrasound‑guided caudal analgesia using bupivacaine provided effective perioperative analgesia and supported the opioid‑sparing anaesthetic technique. Postoperatively, the neonate was electively ventilated in Synchronised Intermittent Mandatory Ventilation (SIMV) mode, then weaned to nasal CPAP and finally to room air without any apnoeic episodes or major complications. The present case highlights the importance of proper planning, multidisciplinary coordination and the use of opioid‑free anaesthesia with ultrasound‑guided regional techniques in extremely preterm neonates. It also strengthens the limited literature on perforated appendix inside an incarcerated inguinoscrotal hernia in neonatal population.