Authors: Khan Z et al.
Cureus 18(2): e104459, February 28, 2026
This case report describes the emergent repair of an incarcerated ventral hernia in a 59-year-old woman with Down syndrome (DS) and Alzheimer’s disease, highlighting diagnostic and postoperative challenges unique to this underrepresented adult population.
The patient presented with a non-reducible 5 cm ventral hernia and underwent emergent robotic repair with mesh placement under general anesthesia. Airway management was carefully tailored to DS-associated anatomic considerations, including neutral neck positioning and minimized cervical extension due to potential atlantoaxial instability and airway anomalies.
Although the intraoperative course was uneventful, the postoperative period was complicated by multiple issues:
• Delayed bowel function and obstipation
• Urinary retention leading to bilateral hydronephrosis
• Bilateral segmental and subsegmental pulmonary emboli on postoperative day four
• Complications related to Foley catheter management
The case underscores several physiologic and perioperative considerations in adults with DS:
Communication barriers and altered pain perception frequently obscure early complication detection. In this patient, postoperative assessment relied heavily on imaging and objective measures due to limited symptom reporting.
Baseline gastrointestinal and genitourinary dysfunction is common in DS, complicating differentiation between expected postoperative changes and pathologic processes. The urinary retention progressed to bilateral hydronephrosis and required extended catheterization, which itself resulted in secondary complications.
Thromboembolic risk may be underappreciated in this population. The patient presented atypically with altered mental status and hypoxia rather than classic pleuritic chest pain. Cross-sectional imaging ultimately confirmed pulmonary emboli.
This report emphasizes the importance of:
• Low threshold for imaging when symptom reporting is unreliable
• Multidisciplinary collaboration (surgery, medicine, urology, radiology)
• Individualized postoperative pathways rather than standardized protocols
• Early consideration of thromboembolic events in high-risk patients
The authors highlight the scarcity of literature regarding emergency general surgery outcomes in adults with DS. Most perioperative data in this population focus on pediatric or cardiac cohorts, leaving a gap in adult surgical evidence.
While this is a single case, it provides a valuable reminder that adults with DS may present atypically, require enhanced postoperative vigilance, and benefit from personalized monitoring strategies rather than routine protocols.
Key Points
• Adults with Down syndrome undergoing emergency surgery may present diagnostic challenges due to communication limitations and altered pain perception.
• Gastrointestinal and genitourinary dysfunction can mask postoperative complications.
• Thromboembolic events may present atypically and require a high index of suspicion.
• Early, proactive imaging may reduce delayed recognition of complications.
• Multidisciplinary, individualized care is essential in this vulnerable population.
Thank you to Cureus for allowing us to summarize and discuss this article.