Published online Jun 25, 2026. doi: 10.5501/wjv.v15.i2.117106
Revised: February 11, 2026
Accepted: March 24, 2026
Published online: June 25, 2026
Processing time: 202 Days and 16.9 Hours
Emergency repair of strangulated hernias in elderly patients with active res
An 80-year-old male with significant comorbidities presented with a strangulated left inguinal hernia and confirmed influenza A (H3N2) infection, associated with abdominal pain, bowel obstruction, and mild hypoxaemia. Emergency robotic
Emergency robotic-assisted repair of strangulated hernia can be safely performed in selected elderly patients with active respiratory viral infection when ap
Core Tip: This case demonstrates the safe and feasible use of emergency robotic-assisted surgery for strangulated hernia transabdominal preperitoneal repair in an elderly patient with an active influenza A (H3N2) infection. Key modifications in surgical approach, anaesthesia, and infection control (such as ultra-low-pressure pneumoperitoneum, ultra-low particulate air filtration, and lung-protective ventilation) were implemented to reduce postoperative complications. The case provides valuable insights into managing high-risk surgical patients with active respiratory viral infections, offering a model for future emergency robotic-assisted surgeries during potential future viral pandemics.
- Citation: Evangelou K, Polydorou A, Petropoulou T. Emergency robotic-assisted repair in an elderly patient with strangulated hernia and active influenza A infection: A case report. World J Virol 2026; 15(2): 117106
- URL: https://www.wjgnet.com/2220-3249/full/v15/i2/117106.htm
- DOI: https://dx.doi.org/10.5501/wjv.v15.i2.117106
Robotic platforms have revolutionized the field of elective surgery by reducing incisions, postoperative pain, and hospital stays thanks to their high-definition 3D visualization and enhanced dexterity, that enable surgeons to perform complex manoeuvres with greater accuracy[1]. Robotic-assisted surgery is gradually gaining ground in emergency settings as well[2], offering much-needed faster intervention times, improved precision, and more stability for navigating the challenges of distorted anatomy, suturing in inflamed tissue, and reducing blood loss[3].
Although the 2021 World Society of Emergency Surgery position paper reported that robotic-assisted surgery can be considered feasible and safe in selected haemodynamically stable patients[4], very little is known about its safety and feasibility in patients with active respiratory system viral infections. Literature is limited to scarce case reports, and most such surgeries had been performed during the coronavirus disease 2019 (COVID-19) pandemic[5]. Concerns that re
Active influenza A infection has been associated with increased perioperative risk, including higher rates of pos
In this high-risk context, robotic surgery may offer advantages over conventional laparoscopy beyond general ergonomic benefits. These include the ability to maintain effective surgical exposure at lower pneumoperitoneum pressures, enhanced precision in strangulated tissue dissection, reduced operative stress in confined anatomical planes, and improved surgeon–patient distancing during prolonged emergency procedures. Importantly, the closed robotic system facilitates controlled smoke evacuation with ultra-low particulate air (ULPA) filtration, potentially reducing aerosolized viral exposure to operating room staff.
Herein, we present the case of an 80-year-old male with multiple comorbidities who successfully underwent em
An 80-year-old male presented to the emergency department with severe abdominal pain, abdominal distension (meteorism), nausea, and inability to pass gas or stool. He also reported cough, shortness of breath, fever, and decreased appetite.
The patient experienced an abrupt onset of left inguinal abdominal pain approximately 6 hours prior to presentation. This was accompanied by a sudden onset of nausea, meteorism, and the absence of gas and stool passage within a few hours. The cough began five days prior to admission and had been dry and non-productive from the outset. Over the past 48 hours, mild exertional dyspnoea and decreased appetite additionally developed. The patient also reported fever exceeding 38 °C; however, he was unable to recall the exact time of measurement or the precise temperature.
The patient denied any similar symptom combination in the past; his present complaints were experienced for the first time.
The patient’s personal history includes arterial hypertension (first diagnosed 15 years ago), diabetes mellitus (first diagnosed ten years ago), mild chronic obstructive pulmonary disease (COPD; diagnosed 7 years ago), and osteopenia (diagnosed 2 years ago). He is classified as class I obese (body mass index 31.0 kg/m2) and American Society of Anesthesiologists score IV, with no history of abdominal surgery.
His medication history includes 5 mg amlodipine twice daily per orally (os), 500 mg metformin tablets twice daily per os, 90 μg albuterol (inhaler) as needed for COPD, 1000 IU vitamin D3 once daily per os, and 200 mg ibuprofen per os taken over the counter for occasional joint pain. He confirmed he was using no herbal supplements or nonprescription medications other than ibuprofen.
He receives an annual dose of influenza vaccine (last dose in October 2024) and has received the pneumococcal polysaccharide vaccine (PPSV23) in October 2019. His vaccination against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was completed with a two-dose Pfizer-BioNTech series vaccine in May 2021, and a booster dose in October 2022.
No adverse drug or food reactions were recorded in his history. He reports a well-balanced (Mediterranean) diet, consisting of regular meals, with no restrictions related to his diabetes or hypertension. He had been instructed to limit his sodium intake and monitor his carbohydrate intake, which he admitted he had omitted.
He is a former smoker of 40 pack-years (quit 5 years ago), consumes a glass of wine occasionally, and denies any history of drug use. He is a retired civil engineer and lives independently with family support for daily activities.
The patient’s family history is unremarkable, besides hypertension (both parents) and coronary heart disease (father). There is no known family history of gastrointestinal cancers or hernias.
Upon presentation, the patient appeared as an elderly white male, 1.70 m in height and weighing 89.5 kg. He was alert but in moderate distress due to pain. His complexion was flushed, without signs of acute respiratory distress.
Vital signs demonstrated elevated blood pressure (17.4/11.4 kPa), regular pulse of 88 bpm, respiratory rate of 20 breaths/minute, temperature of 38.3 °C, and mild hypoxaemia with an oxygen saturation of 88% on room air before supplemental oxygen administration.
Cardiovascular examination revealed normal heart sounds without murmurs or gallops; peripheral pulses were palpable and symmetric, and capillary refill time was < 2 seconds.
Respiratory examination showed clear breath sounds bilaterally, with mild expiratory wheezing, more pronounced in the lower lobes. There were no rales or signs of consolidation, although mild use of accessory muscles suggested increased work of breathing.
Abdominal examination revealed distension with a prominent, tender, and irreducible left inguinal lump measuring approximately 6 cm × 5 cm, consistent with a strangulated inguinal hernia. The overlying skin appeared erythematous and warm to touch. Localized tenderness was present in the left lower quadrant and over the inguinal region. The patient rated the pain as 7/10 on the Visual Analogue Scale. Percussion elicited tympanic notes, consistent with gaseous bowel distension, and bowel sounds were hypoactive.
The preoperative laboratory findings are summarized in Table 1. Mild leucocytosis and C-reactive protein (CRP) elevation suggested an infection or inflammation. All other panels, including coagulation parameters, were normal, except for mild hypoxaemia indicated by a PaO2 of 9.7 kPa on arterial blood gas analysis.
| Panel | Result | Lab range |
| CBC | ||
| WBC (cells/μL) | 13500 | 4500-11000 |
| Hb (g/dL) | 14.2 | 13.0-17.0 |
| PLT (cells/μL) | 220000 | 150000-400000 |
| Inflammatory markers | ||
| CRP (mg/dL) | 62.0 | < 10.0 |
| Renal function | ||
| sCr (mg/dL) | 1.0 | 0.6-1.2 |
| BUN (mg/dL) | 18.1 | 7.0-20.0 |
| GFR (mL/minute/1.73 m2) | 83.0 | > 60.0 |
| Liver function tests | ||
| AST (U/L) | 25.0 | 0-40.0 |
| ALT (U/L) | 22.0 | 0-40.0 |
| Total bilirubin (mg/dL) | 0.7 | 0.1-1.2 |
| ABG | ||
| pH | 7.42 | 7.35-7.45 |
| PaCO2 (kPa) | 5.0 | 4.7-6.0 |
| PaO2 (kPa) | 9.7 | 10.0-13.3 |
| HCO3– (mEq/L) | 23.0 | 22.0-28.0 |
| Virology | ||
| Influenza A PCR Ct (cycles) | 20 |
PCR was positive for the influenza A (H3N2) strain, with a cycle threshold value of 20 cycles, consistent with a high viral load and active infection.
Initially, a chest X-ray was performed considering the possibility of a respiratory tract infection. The lower lung fields demonstrated mild peribronchial thickening bilaterally, with no evidence of pneumonia or parenchymal consolidation. The cardiac silhouette was normal in size, with no free subdiaphragmatic air observed.
Considering the patient’s age, comorbidities, and normal renal function, an intravenous contrast-enhanced computed tomography (CT) scan followed to visualize potential free fluid or gas within the bowel wall and delineate the contents, location, and size of the hernia sac for surgical planning. CT confirmed the presence of a left inguinal hernia with the incarcerated sigmoid colon within the hernia sac. Mild bowel wall oedema was noted, with no signs of ischaemia or perforation, nor free intraperitoneal air or fluid.
The patient was diagnosed with a strangulated left inguinal hernia containing the incarcerated sigmoid colon concurrently with active influenza A (H3N2)-induced bronchitis.
Given the patient’s advanced age, multiple comorbidities, and active respiratory infection, the management strategy was determined after rapid interdisciplinary consultation between the attending surgeon, anaesthesiologist, and infectious disease specialist. The Influenza A infection was immediately addressed with oseltamivir 75 mg twice daily, continued for a total of seven days.
Despite the presence of active influenza A infection, immediate surgical intervention was mandated due to clinical and radiological features consistent with hernia strangulation, including bowel obstruction and risk of ischemia. Delaying surgery in this context carries a well-established risk of bowel necrosis, perforation, sepsis, and mortality, which outweighs the risks associated with proceeding during active viral infection. Non-operative management was therefore not considered a safe alternative, and surgery was performed under enhanced anaesthetic and infection-control precautions. To minimize surgical trauma and postoperative complications such as wound infection, pneumonia, and delayed recovery, a minimally invasive approach was selected.
The operating surgeon was a board-certified minimally invasive and robotic colorectal consultant with formal fellowship training and experience exceeding 250 robotic-assisted procedures, including numerous emergency cases. The team included two experienced bedside assistants (each with > 150 robotic cases), a scrub nurse specialized in robotic instrumentation, and an anaesthesiologist trained in prolonged minimally invasive procedures. The institution has performed more than 150 robotic-assisted operations, ensuring full team familiarity with the platform and workflow.
Preoperatively and considering the patient’s mild hypoxaemia, history of COPD, and respiratory reserve compromise due to the infection, the anaesthesia team developed an adapted lung-protective ventilation strategy to reduce the risk of acute respiratory distress syndrome (ARDS), exacerbation of existing pulmonary conditions, and postoperative res
A strategy of 6 mL/kg of ideal body weight for tidal volume was used, in line with ARDS network recommendations[11], to minimize the risk of ventilator-induced lung injury (VILI). A plateau pressure of < 2.45 kPa was maintained during mechanical ventilation to minimize the risk of barotrauma or VILI, while moderate positive end-expiratory pressure (0.7 kPa) was applied to prevent atelectasis, improve oxygenation, and ensure lung recruitment. Oxygen therapy was optimized to maintain oxygen saturation by pulse oximeter (SpO2) levels > 95%, using fraction of inspired oxygen adjustments as necessary.
Surgical staff were required to wear personal protective equipment including N95 filtering facepiece respirators. All team members in direct contact with the patient wore face shields and surgical hoods in addition to the standard gloves and gowns. Robotic surgical instruments were sterilized using high-temperature autoclaving and ethylene oxide sterilization, while a closed-loop insufflation system with ULPA filters was utilized for gas flow and ventilation during surgery.
For the r-TAPP approach, the patient was positioned in minimal Trendelenburg position to avoid exacerbating his hypoxaemia. An ultra-low-pressure pneumoperitoneum (ULPP) of 1.0 kPa was deliberately selected instead of the standard 1.6-2.0 kPa to minimize respiratory compromise while preserving adequate exposure through robotic articulation and stable 3D visualization.
The da Vinci Xi robotic system was used, with an 8 mm supraumbilical camera port and three 8 mm instrument ports, one in the left lower quadrant and two in the right lower quadrant.
Upon entry and exploration of the abdominal cavity, the incarcerated left inguinal hernia was identified with the sigmoid colon trapped within its sac. The bowel was assessed for viability, and there were no signs of ischaemia or necrosis. The hernia sac was dissected, and the incarcerated bowel was reduced (Figure 1).
Following successful bowel reduction, the preperitoneal space was dissected to expose the inguinal region. In the absence of bowel necrosis, perforation, or enteric spillage, the operative field was not considered contaminated, and standard mesh-based repair was therefore performed using a non-absorbable polypropylene mesh (Prolene) to cover the hernia defect. The mesh was placed preperitoneally to cover the inguinal ring tension-free and was secured in place using sutures (Figure 2). The peritoneum was closed over the mesh, and the surgical site was inspected for haemostasis.
The robotic instruments were carefully removed from the operative field under direct visualisation via the camera. Before closure, it was ensured that the preperitoneal space was fully clear of any residual tissue or foreign bodies.
The peritoneal layer was closed using absorbable monofilament sutures (Monocryl 1-0) in a continuous running technique. The 8 mm supraumbilical port site was closed using a subcuticular absorbable suture (Monocryl), size 2-0 for deep closure and 4-0 for the superficial layer. A single-layer closure was performed with a running subcuticular stitch. The three 8 mm port sites were closed with absorbable sutures (Vicryl 3-0) using a simple interrupted technique. In addition to suturing, 3M Steri-Strips were applied over the port sites.
The surgery lasted a total of 85 minutes and the estimated blood loss was minimal (20 mL). No intraoperative complications were recorded.
The patient was extubated immediately after surgery and in the operating room. He was then transferred to the high-dependency unit (HDU) for observation, where oxygen therapy was administered at 2 L/minute via nasal cannula to maintain SpO2 > 95%. A chest X-ray was performed postoperatively to assess for pneumothorax or infection worsening, with none detected.
It was decided that the patient would remain in the HDU until discharge, as part of the infection control measures. Oseltamivir, amlodipine, metformin, and vitamin D3 were continued during his hospitalization.
On the first postoperative day, his laboratory results showcased a white blood cell count of 12500 cells/μL, a CRP of 10 mg/dL, and no electrolyte imbalances, indicative of infection remission. His vital signs and respiratory function remained stable throughout his postoperative course, while the wound was inspected daily for signs of infection.
The patient was discharged on the second postoperative day. Follow-up was scheduled for one week postoperatively, to assess hernia repair and recovery, and he was instructed to continue oseltamivir twice daily until his appointment. The patient remained influenza-negative upon discharge, and all 12 exposed healthcare workers tested negative throughout 7-day surveillance.
The patient has not developed any postoperative or infection complications post-discharge and has shown no symptoms or signs of hernia recurrence to date.
Influenza A is the most prevalent strain to infect humans and the only one known to cause flu pandemics[12]. The virus primarily infects the upper and lower respiratory tract and can cause a range of complications including pneumonia, ARDS, cytokine storms, and exacerbation of preexisting lung conditions such as COPD[13]. Since 1968, most seasonal influenza epidemics have been caused by the H3N2 subtype[14], which typically causes more severe disease, particularly in elderly patients and those with underlying chronic comorbidities[15]. In our patient, the mild hypoxemia and dry cough were indicative of viral bronchitis, a complication commonly associated with H3N2 infection.
Surgery in patients with an active influenza infection is usually postponed for one to two weeks, although data on surgical outcomes in such patients is very limited for both children and adults[16-18]. The strongest evidence in literature is a 2023 propensity-score matched study including more than 30000 surgical patients, which concluded that a history of influenza infection in the first preoperative week increases the risk of postoperative pneumonia, septicaemia, acute renal failure, urinary tract infection, intensive care unit admission, and prolongs overall length of stay[19].
In our case, the urgency of hernia repair to avoid bowel ischaemia and sepsis overrode the risks associated with the influenza infection. In such emergency cases, general anaesthesia can be more complex depending on infection severity, due to potentially increased airway inflammation, decreased pulmonary reserve, and impaired oxygenation[20].
Moreover, a Swedish 2023 observational study over six influenza seasons revealed that the H3N2 subtype is associated with an increased risk of hospital dissemination[15]; additional infection prevention and control measures were therefore necessary in our case, although there are currently no established guidelines when operating on patients with influenza. In light of the COVID-19 pandemic, we decided to implement safety precautions recommended by guidelines for surgery of confirmed or suspected SARS-CoV-2 patients[21], considering the patient’s viral load was moderate. The absence of positive samples in consecutive healthcare staff testing in the first postoperative week in our report confirms the effectiveness and accuracy of implementation. Furthermore, multidisciplinary team discussion deemed robotic-assisted surgery safe considering the patient’s infection status, as cohort studies during the pandemic have validated its safety for COVID-19 patients[5].
Intraoperatively, the ventilation adaptations we applied to reduce the risk of viral aerosolisation and minimize exposure to the surgical team were additionally lung-protective and complemented by the reduction of pneumoperitoneum pressure. Pressures as low as 0.5 kPa (extremely-low-pressure or ULPP) have been successfully maintained during robotic-assisted general surgery and associated with reduced changes in intraoperative lung compliance, lower demand for postoperative analgesics, and improved quality of life during early stages of postoperative rehabilitation[22]. Studies utilising low-pressure pneumoperitoneum consider intraoperative emergencies (e.g. significant bleeding) as events necessitating intra-abdominal pressure elevation to 2.0-2.4 kPa for more than 2-5 minutes[23].
Beyond its technical feasibility, this case underscores the potential advantages of the robotic platform in managing high-risk patients with active respiratory infections. Robotic-assisted surgery offers enhanced precision, tremor filtration, and stable instrument control under low-pressure pneumoperitoneum, thereby minimizing the impact on pulmonary mechanics and reducing the risk of intraoperative hypoventilation[24]. In addition, the smaller incisions, improved ergonomics, and reduced postoperative pain contribute to earlier mobilization and better respiratory function in minimally invasive surgery overall[25]. Importantly, the physical separation of the console from the patient further limits aerosol exposure for the surgical team, an advantage highlighted during the COVID-19 pandemic. These factors co
To our knowledge, our report describes the first robotic-assisted general surgery case to have been performed in a patient with an active respiratory tract infection in emergency settings. Nevertheless, it is still limited by the fact that it is a single case with short-term (< 1 year) follow-up. Although the Ct value for Influenza PCR was used to infer viral load, no detailed quantitative load assessment followed. Moreover, the case involved a patient with a specific set of comor
Future research should therefore focus on tailoring robotic surgical protocols to better prepare operators for potential influenza pandemics, and investigate the role of robotic-assisted general surgery in larger patient cohorts with active infections and even consider the exploration of advanced technologies such as artificial intelligence and augmented reality[26]. Until then, we believe that the present case report is a strong first indication that the robotic platform is a feasible alternative to open surgery in patients with respiratory infections in emergency situations, and safe for both patients and healthcare professionals when strict infection prevention and control measures are enacted.
This case represents the first reported experience of emergency robotic-assisted repair of a strangulated hernia in an elderly patient with multiple comorbidities and active influenza A (H3N2) infection. It suggests that, in carefully selected cases, robotic-assisted surgery may be a feasible option for managing complex surgical emergencies under high-risk conditions. Favorable perioperative outcomes in this case were associated with targeted anaesthetic and surgical adaptations, including lung-protective ventilation and ULPP, as well as strict adherence to infection-control protocols. While limited by its single-case nature, this report supports further investigation of emergency robotic-assisted surgery in patients with active respiratory infections through larger studies to better define indications, safety profiles, and standardized protocols.
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