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Background and Aims Pain management for Vertical Rectus Abdominis Musculocutaneous (VRAM) Flap can be challenging due to a large surgical incision. We present a case of a 65-year-old female admitted for correction of recidivate complex uterovaginal prolapse and VRAM Flap. We aim to demonstrate the benefits of combined anesthesia for this type of surgery.

Methods An epidural catheter was placed at L3/L4 level with an initial bolus of 10ml of 0.75% ropivacaine administered without relevant hemodynamic instability. After induction of total intravenous anesthesia (propofol and remifentanil), 2mg of epidural morphine was administered to spread the analgesia. Another bolus of 7 ml of 0.2% ropivacaine was administered only 5h after. The maintenance dose of remifentanil was low (up to less than 0,05-0,10 mcg/kg/min). Analgesia was complemented with cetorolac 30mg, paracetamol 1g and metamizol 2g. The procedure lasted for 7 hours and at the end, a patient-controlled epidural infusion (PCEA) was connected with 0,1% ropivacaine with a continuous infusion of 5ml/h and 4ml patient-controlled bolus with a lockout of 20min.

Results Post-operative pain was well controlled, 2 out of 10 (numerical rating scale pain) at rest and movement at 0h and 12h without bolus attempts in the PCEA nor opioid rescue analgesia.

Conclusions Patient-controlled epidural infusion limited postoperative opioids necessities and their associated side effects while providing controlled analgesia in VRAM flap surgeries.