Perioperative anesthetic management of portal cavernoma in a patient undergoing total abdominal hysterectomy with bilateral salpingectomy under fractional combined spinal–epidural anesthesia: A case report

Background: Cavernous transformation of the portal vein (portal cavernoma) is a chronic sequela of portal vein thrombosis characterized by porto-portal collateral formation and portal hypertension. Perioperative anesthetic management is challenging due to altered splanchnic hemodynamics, risk of bleeding, and potential coagulation abnormalities. Case Presentation: A 38-year-old female with radiological evidence of portal cavernoma and preserved hepatic function was scheduled for total abdominal hysterectomy with bilateral salpingectomy for abnormal uterine bleeding. Preoperative coagulation profile, platelet count, and liver function were within normal limits. Upper gastrointestinal endoscopy excluded varices. After multidisciplinary clearance, she was classified as ASA Physical Status II. A Fractional Combined Spinal–Epidural technique was administered using Hyperbaric Bupivacaine with Nalbuphine and Clonidine. Intraoperative hemodynamics remained stable despite an estimated blood loss of 600 mL. No vasopressors or transfusion were required. The postoperative course was uneventful. Conclusion: In carefully selected patients with portal cavernoma and preserved coagulation status, Fractional Combined Spinal–Epidural anesthesia provides controlled sympathetic blockade and stable perioperative hemodynamics during major abdominal surgery.