The key to successful management in the present case was the multidisciplinary collaboration between the anesthesia and surgical teams to develop the treatment strategy.

The anesthesia method for inguinal hernia repair differs depending on the surgical procedure [2, 5]. There are two options, laparoscopic surgery or open surgery, each with their own advantages and disadvantages, including modes of anesthesia [6, 7]. The treatment strategy is often decided before appropriate discussion with the anesthesiologist to elucidate their perspective, even in cases in which there seem to be anesthetic problems. A tailored approach is recommended, taking into account the expertise of both the anesthesia and surgical team members [8].

In our hospital, infant cases of inguinal hernia are usually treated by laparoscopic surgery under general anesthesia with tracheal intubation and peripheral nerve block (Discussed Option #1, Table 1). As part of the discussion regarding this patient, disadvantages of laparoscopic surgery were noted, including consideration of the necessity of intubation and CO2 insufflation because he had suspected SGS and chronic lung disease (CLD). Our surgeons preferred laparoscopic surgery under general anesthesia with tracheal intubation because surgery for this patient would be time consuming and difficult because he was born premature and had a history of repeated incarceration. Also, there are advantages of laparoscopic surgery, which can identify and treat a contralateral inguinal hernia occurring in ex-premature infants. If Discussed Option #1 (Table 1) was performed according to the surgeons’ initial preference, there were risks of difficult ETT removal, and concerns regarding respiratory management under intubation postoperatively and PICU admission. In the worst case scenario, this could result in the need for tracheostomy. As a result of discussion, it was decided that avoiding tracheal intubation should be prioritized.

If surgeons elect for open surgery as a procedure, spinal anesthesia is thought to be a good option because tracheal intubation can be avoided. If airway evaluation and open surgery are planned to be performed at the same time (Discussed Option #2, Table 1), the RBS should be performed under general anesthesia first, and the airway may be secured with a supraglottic device, or ETT, depending on the findings of subglottic lesions. Performing the surgery and airway evaluation simultaneously nullifies the advantage of choosing open surgery, because the open surgery does not require general anesthesia in the first place.

In Discussed Option #3 (Table 1), the patient would require anesthesia twice and a longer hospital stay. However, spontaneous breathing can be preserved in open hernia surgery under spinal anesthesia and RBS, so it is highly likely that tracheal intubation can be avoided. Considering the history of intubation in the early stages of our patient’s life and difficult insertion of age-appropriate size of ETT at the induction of previous anesthesia, and with due consideration of CT findings and the patient’s physical symptoms, it was decided to be important to avoid tracheal intubation, despite the degree of SGS being mild [9]. We concurred that Discussed Option #3 was the best strategy.

The true incidence of acquired SGS and cysts and intubation-related laryngeal injury is difficult to assess. The duration of intubation is a significant risk factor [10]. Unless there is a strong suspicion of SGS, the evaluation is not always performed, even when the patient has a history of intubation or premature birth. Outpatient follow-up is usually performed by neonatologists or pediatricians, but their low awareness of SGS because of low prevalence may also contribute to the low awareness of anesthesia-related risks [11]. Even with persistent respiratory symptoms and a history of long-term intubation, SGS may be misdiagnosed as CLD because symptoms of SGS may mimic the characteristic features of CLD [12] and because of the history of premature birth often accompanies CLD. Anesthesiologists who care for children with such medical histories and respiratory symptoms must therefore be cautious in their preoperative physical evaluation.

We provided a secure perioperative strategy to perform inguinal hernia surgery and airway assessment in an infant whose surgery had been cancelled at another hospital due to SGS. The patient underwent open hernia surgery under spinal anesthesia and diagnostic RBS under tubeless general anesthesia separately. No tracheal intubation was performed in either operation. Discussion weighing risks and benefits may deduce the safest and most appropriate anesthesia method.