Contralateral pneumothorax during retroperitoneal laparoscopic donor nephrectomy: A case report

Bochdalek Hernia in an Adult Causing Intraoperative Complication

Bochdalek hernias are rarely diagnosed in adults and account for 0.17-6% of all diaphragmatic hernias. It is a congenital diaphragmatic hernia caused by a defect in the posterior attachment of the diaphragm due to a failure of the pleuroperitoneal membrane closure in utero. This may rarely cause chest pain, respiratory symptoms, or gastrointestinal symptoms. In this study, we present a case of a laparoscopic paraesophageal repair via Nissen fundoplication. The incidental finding and subsequent repair of a Bochdalek hernia during this case may have resulted in complications of the surgery including pneumothorax due to the defect in the pleuroperitoneal membrane. 

Use of intraoperative ultrasonography for identification and management of pneumothorax caused by iatrogenic diaphragm defect: a case report and literature review

Transthoracic ultrasound has been widely accepted for the evaluation of many thoracic diseases, including pleural effusion, atelectasis, pneumothorax, and pneumonia with subpleural effusion. Application of ultrasonography for the diagnosis of pneumothorax is an effective and timely intraoperative technique. We herein present a patient who developed pneumothorax following diaphragmatic injury during laparoscopic cholecystectomy. The pneumothorax was rapidly identified by bedside ultrasound. The compressed lung was successfully re-expanded using positive end-expiratory pressure (PEEP) ventilation under real-time ultrasound monitoring, and closed thoracic drainage was avoided. Therefore, the correct use of ultrasound can identify the adequate PEEP level that is able to promote resolution of pneumothorax induced by diaphragmatic injury.

Pneumoperitoneum-induced pneumothorax during laparoscopic living donor hepatectomy: a case report

Background

We present a living donor case with an unexpected large-volume pneumothorax diagnosed using lung ultrasound during a laparoscopic hepatectomy for liver transplantation (LT).

Case presentation

A 38-year-old healthy female living donor underwent elective laparoscopic right hepatectomy. The preoperative chest radiography (CXR) and computed tomography images were normal. The surgery was uneventfully performed with tolerable CO₂ insufflation and the head-up position. SpO₂ decreased and airway peak pressure increased abruptly after beginning the surgery. There were no improvements in the SpO₂ or airway pressure despite adjusting the endotracheal tube. Eventually, lung ultrasound was performed to rule out a pneumothorax, and we verified the stratosphere sign as a marker for the pneumothorax. The surgeon was asked to temporarily hold the surgery and cease with the pneumoperitoneum. Portable CXR verified a large right pneumothorax with a small degree of left lung collapse; thus, a chest tube was inserted on the right side. The hemodynamic parameters fully recovered and were stable, and the surgery continued laparoscopically. The surgeon explored the diaphragm and surrounding structures to detect any defects or injuries, but there were no abnormal findings. The postoperative course was uneventful, and a follow-up CXR revealed complete resolution of the two-sided pneumothorax.

Conclusion

This living donor case suggests that a pneumothorax can occur during laparoscopic hepatectomy due to the escape of intraperitoneal CO₂ gas into the pleural cavity. Because missing the chance to identify a pneumothorax early significantly decreases the safety for living donors, point-of-care lung ultrasound may help attending physicians reach the final diagnosis of an intraoperative pneumothorax more rapidly and to plan the treatment more effectively.

Carbon dioxide pneumothorax following retroperitoneal laparoscopic partial nephrectomy: a case report and literature review

Background

Laparoscopy has many advantages when used to assist surgery. However, pneumothorax, as a rare but potentially life-threatening complication, it requires rapid recognition and treatment. CO₂ pneumothorax may be distinct from air pneumothorax. Here we present a case with unexpected large and symptomatic CO₂ pneumothorax and treated successfully in a conservative way.

Case presentation

A 27-year-old woman who was scheduled a laparoscopic partial nephrectomy received general anesthesia. At the end of surgery, she waked up and got spontaneous breathing. However, she developed a sudden fall in SpO₂ (approximately 30%) and blood pressure with subsequent unconsciousness after switching mechanical ventilation to spontaneous mode. With immediate manual ventilation, SpO₂ and blood pressure recovered simultaneously and the patient regained consciousness. Point-of-care chest X-ray revealed a large, right pneumothorax occupying 70% of the hemi-thorax. Without chest drainage, she was extubated in the operating room and treated with supplemental facial mask oxygen therapy in PACU. On the postoperative 5th day, she was discharged without any further complication.

Conclusion

Retroperitoneal laparoscopic surgeries are likely to bring about severe capno-thorax, which could be absorbed rapidly. Chest X-ray could be used to assist diagnosis but point-of-care transthoracic ultrasound is recommended. Even severe capno-thorax could be treated conservatively. This case highlights the awareness and therapeutic choice of noninvasive management for capno-thorax.