Bilateral pneumothorax associated with laparoscopy. A case report of a rare hazard and review of literature

Postoperative Pulmonary Complications Following Laparoscopy

Postoperative pulmonary complications (PPCs) unrelated to anesthesia, especially hydropneumothorax, are rare after gynecologic laparoscopy. Hydropneumothorax can cause respiratory failure and be life-threatening, however. Awareness, prompt diagnosis, and timely intervention are crucial for clinical management. We review the literature for PPCs, including pneumothorax, hydrothorax, hydropneumothorax, and pleural effusion following laparoscopy, and also present a recent case of hydropneumothorax seen at our institution.

Contralateral pneumothorax during retroperitoneal laparoscopic donor nephrectomy: A case report

This report presents a case of a 46-year-old woman in whom contralateral pneumothorax occurred during retroperitoneal laparoscopic donor nephrectomy without any evidence of diaphragmatic injuries. After the start of carbon dioxide-induced pneumoperitoneum, the patient's end-tidal carbon dioxide pressure and heart rate suddenly increased. The surgery was then paused, and a chest X-ray revealed a right pneumothorax accompanied by pneumomediastinum. After a thoracostomy tube was inserted, these symptoms immediately improved. After conversion to an open procedure, the surgery was completed. The thoracostomy tube was removed the next day, and the patient was discharged without any complications. As the pneumothorax occurred on the opposite side to the operative field and there was no evidence of diaphragmatic injury, it is suspected to have been caused by a pneumomediastinum-induced rupture of the barrier between the mediastinum and pleural space. This may have occurred due to the insufflated carbon dioxide gas passing directly into the mediastinum and then the pleural space.

THORACIC COMPLICATIONS DURING UROLOGICAL LAPAROSCOPY

PURPOSE

We documented thoracic related complications during urological laparoscopic surgery.

MATERIALS AND METHODS

A total of 1129 patients underwent major urological laparoscopic procedures in a 5-year period. Operative reports and postoperative radiographic reports were retrospectively reviewed to identify patients with thoracic related medical and surgical sequelae. Of the patients 619 (55%) underwent at least 1 chest x-ray in the immediate or early postoperative period. In the remaining 510 patients (45%) there was no clinical indication to perform chest x-ray.

RESULTS

Of 619 patients undergoing chest x-ray 438 (71%) were completely normal. Medical pulmonary complications, surgical thoracic complications and subclinical, incidentally detected gas collections in the chest were identified in 12.6%, 0.5% and 5.5% of patients, respectively. Medical complications in 12.6% of cases included pulmonary infiltrate/atelectasis in 9.7%, pleural effusion in 4.8% and pulmonary embolus in 0.3%. Surgical complications included symptomatic pneumothorax in 4 patients (0.35%), hemothorax in 1 (0.08%) and chylothorax in 1 (0.08%). Subclinical abnormal thoracic gas collections were radiographically noted in 34 of the 619 patients (5.5%) on chest x-ray, including pneumomediastinum in 19 (3.1%), pneumothorax in 10 (1.6%) and pneumopericardium in 5 (0.8%). Overall 36 of 40 (90%) thoracic surgical complications (3) and subclinical, incidentally detected gas collections (33) occurred during retroperitoneal laparoscopy. Re-intervention was necessary in 6 patients (0.5%), namely pulmonary embolus requiring vena caval filter placement in 3 (0.3%), pneumothorax requiring a chest tube in 2 (0.17%) and hemothorax requiring emergency open thoracotomy in 1 (0.08%). No patient underwent open conversion to complete the initial proposed operation.

CONCLUSIONS

Due to its high solubility the expectant management of incidental CO2 pneumothorax, pneumopericardium and pneumomediastinum is recommended initially in the clinically stable patient. Inadvertent diaphragmatic entry can be satisfactorily repaired laparoscopically without open conversion. Although it is rare, surgical thoracic complications are potentially life threatening, requiring prompt identification and management.

Pneumomediastinum, pneumothorax and subcutaneous emphysema complicating MIS herniorrhaphy

PURPOSE

Videoscopic herniorrhaphy is being performed more frequently with advantages claimed over the conventional open approach. This clinical report describes a pneumothorax, pneumomediastinum and subcutaneous emphysema occurring at the end of an extraperitoneal videoscopic herniorrhaphy.

CLINICAL FEATURES

A 25 yr old ASA I man presented for elective extraperitoneal videoscopic hernia repair. Following intravenous induction with fentanyl, midazolam and propofol a balanced anesthetic technique using enflurane in N2O and O2 was used. Apart from a prolonged operating time (195 min), the procedure and anesthetic was uneventful. At the conclusion of the operation, prior to reversal of neuromuscular blockade extensive subcutaneous emphysema was noted on removal of the surgical drapes. Chest radiography revealed a pneumomediastinum and pneumothorax. A 25 FG intercostal tube was inserted and connected to an underwater seal drain. Sedation and positive pressure ventilation was maintained overnight to permit resolution and avoid airway compromise. The clinical and radiological features had resolved by the next morning and the patient's trachea was extubated. His subsequent recovery was uneventful.

CONCLUSION

Pneumothorax and pneumomediastinum are well recognised complications of laparoscopic techniques but have not been described following extraperitoneal herniorrhaphy. In this report we postulate possible mechanisms which may have contributed to their development, including inadvertent breach of the peritoneum and leakage of gas around the diaphragmatic herniae or tracking of gas retroperitoneally. The case alerts us to the possibility of this complication occurring in patients undergoing videoscopic herniorrhaphy.

Anesthesia for gynecologic laparoscopy

Despite developments in instruments and improvements in surgical and anesthesia techniques, laparoscopy is still associated with complications that may be lethal, including those related to anesthesia. Both anesthesiologist and surgeon must thoroughly understand potential complications of the procedure, including physiologic alterations, principles of anesthetic management and postoperative pain control, and problems related to anesthesia. (J Am Assoc Gynecol Laparosc 6(3):245-258, 1999)

Randomized, prospective, single-blind trial of a new parallel technique of Veress pneumoperitoneum needle insertion versus the conventional closed method

OBJECTIVE

To evaluate the safety and effectiveness of a new closed parallel technique of Veress needle insertion and to compare this method with the conventional closed approach.

DESIGN

Sequential, randomized, prospective, single-blind clinical trial.

SETTING

University hospital.

PATIENT(S)

Women undergoing elective diagnostic and/or operative laparoscopy. Subjects (n = 200) were assigned randomly to undergo the conventional closed method (group 1; n = 100) or the new parallel technique (group 2; n = 100) of Veress needle insertion.

INTERVENTION(S)

Randomization of the patients was performed in the operating room. The investigator performed both diagnostic and operative laparoscopy in both study groups.

MAIN OUTCOME MEASURE(S)

Safety and effectiveness of the needle insertion technique.

RESULT(S)

There were no significant differences in demographics between the groups, or in the time required for Veress needle insertion to establish pneumoperitoneum. There were no nonlethal major or minor intraoperative complications associated with either laparoscopic approach.

CONCLUSION(S)

There is no significant disadvantage to the parallel technique of Veress pneumoperitoneum needle insertion compared with the conventional closed approach. This new technique avoids the anatomic location of large vessels during insertion and may serve as a safeguard to decrease the potential for lethal laceration of a major vessel.

Respiratory compliance during laparoscopic hiatal and inguinal hernia repair

PURPOSE

Side stream spirometry with dynamic compliance displayed as pressure-volume loops, has enabled early detection of CO2 pneumothorax during pneumoperitoneum. We compared dynamic compliance profiles of two laparoscopic procedures with different patient positions.

METHODS

In 26 patients, scheduled either for laparoscopic fundoplication in a head-up tilt or inguinal herniorrhaphy in a head-down tilt, dynamic compliance was measured with continuous spirometry from anaesthesia induction until skin closure. Control pressure-volume loops were saved in the horizontal position before surgery and compared with succeeding loops in the head-up/head-down tilt before pneumoperitoneum, during pneumoperitoneum in the horizontal and the tilt position, after evacuation of pneumoperitoneum in the tilt and finally in the horizontal position.

RESULTS

Pneumoperitoneum reduced compliance in both groups by 35% (P < 0.01). Head-down tilt decreased compliance by 12% before and during pneumoperitoneum (P < 0.01). Head-up tilt increased compliance by 4% before pneumoperitoneum (P < 0.05), but during pneumoperitoneum it had no effect. After evacuation of pneumoperitoneum compliance returned immediately to control in head-up tilt, but remained reduced in head-down tilt and was not at control after adopting horizontal position (P < 0.05). Difference between the groups was significant (P < 0.01) in the head-up/head-down tilt before, during and immediately after pneumoperitoneum.

CONCLUSION

Both pneumoperitoneum and head-up and head-down positions had characteristic effects on dynamic compliance. Simultaneous display of sequential pressure-volume loops enabled immediate detection of changes in respiratory mechanics.

Subcutaneous emphysema and pneumothorax during laparoscopy for ectopic pregnancy removal

We report a case of subcutaneous emphysema and pneumothorax during laparoscopic removal of ectopic pregnancy. Increases in airway pressures and end-tidal carbon dioxide, simultaneously with decrease of lung compliance, led quickly to diagnosis of pneumothorax. We recommend a careful monitoring of these variables during laparoscopic procedures. Carbon dioxide pneumothorax can occur even without pulmonary or pleural trauma.

Laparoscopic surgery and its potential for medical complications

Laparoscopic surgery is very popular among physicians and patients because this technique is associated with safety, shorter hospital stay, early return to normal activity, and cosmetic acceptance of the operative scar. Although the procedure involves minimal invasion and tissue damage, it has potentially serious complications, including cardiopulmonary effects that result mainly from hypercarbia and raised intraabdominal pressure caused by pneumoperitoneum. Absorbed carbon dioxide from the peritoneal cavity tends to cause acidosis. Leakage of the gas into tissue spaces may induce subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumopericardium. Cardiac effects include arrhythmias, hypotension, cardiac arrest, gas embolism, pulmonary edema, and myocardial ischemia or infarction. Some of these effects, though rare, are serious and potentially fatal. Physicians should anticipate these problems in their patients undergoing laparoscopic procedures. This review discusses the technique of and physiologic considerations in laparoscopic surgery as well as its potential complications.

Pneumothorax complicating laparoscopic ureterolysis

In a 71-year-old female marked left-sided ureteral stenosis secondary to retroperitoneal fibrosis was diagnosed. Since conservative therapy with cortisone had failed, laparoscopic ureterolysis was performed. Following tracheal intubation the lungs were ventilated with 40 vol% O2 in air and isoflurane 0.5-2%, using a positive end-expiratory pressure of 6 cm H2O. A CO2 pneumoperitoneum was established with a pressure-controlled high-flow insufflator; the intraabdominal pressure during the procedure was 14 mm Hg. Two hours after gas instillation, the peak airway pressure increased from 22 to 40 cm H2O, and the PaCO2 from 45 to 70 mm Hg. Breath sounds over the right lung were no longer heard, and subcutaneous emphysema was noted over the neck and face. An intraoperative chest X-ray confirmed a right pneumothorax. Following peritoneal gas evacuation, the PaCO2 returned to 35 mm Hg, the subcutaneous emphysema diminished, and a repeat chest X-ray showed complete resolution of the pneumothorax. The course of this event led us to the conclusion that the pneumothorax was due to diffusion of CO2 from the peritoneal to the pleural cavity through congenital defects in the diaphragm. Ureterolysis could be continued by laparotomy.

Pneumothorax during laparoscopic fundoplication: diagnosis and treatment with positive end-expiratory pressure

Pneumothorax can develop during laparoscopy, particularly during laparoscopic fundoplication, since the left parietal pleura is exposed and can be torn during dissection in the diaphragmatic hiatus. Such an event will result in specific pathophysiologic changes, since CO2, under pressure in the abdominal cavity, will pass into the pleural space. The aim of this study was to document the pathophysiologic changes induced by pneumothorax, and to evaluate the benefit of positive end-expiratory pressure (PEEP) to treat pneumothorax. Forty-six ASA physical status I and II patients scheduled for laparoscopic fundoplication were monitored extensively; heart rate, mean arterial pressure, end-tidal CO2 (PETCO2), oxygen saturation of hemoglobin (Spo2), minute ventilation, tidal volume, dynamic total lung thorax compliance, and airway pressures were recorded. In 25 patients, oxygen uptake, CO2 elimination and arterial blood gases were also measured. Pneumothorax was diagnosed in seven patients. It resulted in the following pathophysiologic changes: decrease in total lung thorax compliance, increase in airway pressures, and increase in CO2 absorption. Consequently, PACO2 and PETCO2 also increased. Spo2, however, remained normal. The use of PEEP largely corrected these respiratory changes. None of these pneumothoraces required drainage. These data suggest that pneumothorax is common during laparoscopic fundoplication. Early diagnosis is possible by simultaneous monitoring of PETCO2, total lung thorax compliance, and airway pressures. Finally, treatment with PEEP provides an alternative to chest tube placement when pneumothorax is secondary to passage of peritoneal CO2 into the interpleural space.

Early detection of CO2 pneumothorax with continuous spirometry during laparoscopic fundoplication

In two patients, operated on because of gastroesophageal reflux, carbon dioxide pneumothorax developed during laparoscopic Nissen fundoplication. In both instances, decrease of lung compliance and a change of pressure-volume loop configuration, computed and illustrated with on-line spirometry, led quickly to diagnosis of this complication. We conclude that continuous spirometry is valuable as an early indicator of intraoperative pneumothorax.

Complications of laparoscopy and thoracoscopy

Laparoscopy was first performed at the turn of the century, but it was not until the introduction of laparoscopic cholecystectomy that the procedure became widely adopted by general surgeons. Since then, traditional open procedures, including cholecystectomy, exploratory laparotomy, colectomy, hernia repair, and appendectomy, are being widely performed laparoscopically. The advantages of laparoscopic surgery, including less postoperative pain due to smaller surgical incisions, shorter hospital stay, quicker return to preoperative activity, and superior cosmesis, resulted in widespread popularity with both surgeons and patients. In certain situations, the traditional method may be superior to the laparoscopic approach, as may be the case with laparoscopic hernia repair. It is difficult to justify converting a local, extraperitoneal, 45-minute, outpatient inguinal hernia repair in a virgin groin into a general anesthetic, transperitoneal, 2-hour plus, possibly inpatient laparoscopic procedure with the implantation of mesh. However, data may indicate that this operation does indeed have benefits. We must, therefore, carefully study such new operations. With the advent of a new surgical procedure, both surgeons and anesthesiologists must be familiar with the various complications unique to this technique. If recognized early, potentially life-threatening complications, including gas embolization and tension pneumothorax, can be corrected.

Complications of therapeutic laparoscopy

Laparoscopic surgery holds great promise as a technique for reducing hospital stay and convalescence. Although advantages in hospital cost cannot be shown for all such procedures, improvements in technique and operator experience will undoubtedly improve the situation. Analysis of the pertinent physiologic aspects and complication rates indicates that laparoscopy is not minimally invasive, but rather exposes the patient to many of the risks normally incurred by open procedures. Enthusiasm for the use of these techniques must be tempered by good judgment and scientific evidence supporting equivalent or better long-term results at equal or lower rates of morbidity and mortality.

Pneumothorax associated with laparoscopic cholecystectomy

Pneumothorax is an uncommon but potentially serious complication that can occur during laparoscopic procedures. A patient under-going laparoscopic cholecystectomy developed an 80% pneumothorax during the course of the procedure and required chest tube insertion. She then underwent an uneventful recovery. The etiology of this complication as well as methods for avoiding this problem have been reviewed. Because of the potential serious nature of this complication, it is imperative that the surgeon be aware of the possibility and implement appropriate immediate therapy.

Laparoscopic fundoplication: a new technique with new complications?

We report pneumomediastinum, pneumopericardium, and subcutaneous emphysema occurring in patients who underwent laparoscopic fundoplication in our clinic. These complications might adversely affect hemodynamics during this procedure.

Subcutaneous emphysema, pneumomediastinum and pneumothorax complicating laparoscopic vagotomy. Report of two cases

Two patients developed subcutaneous emphysema and pneumomediastinum during laparoscopic vagotomy. One of the patients also had a pneumothorax which produced a sudden increase in end-tidal carbon dioxide concentration preceding arterial oxygen desaturation. The pneumothorax was drained with an intercostal cannula. The patient required a twofold increase in minute ventilation to maintain normocarbia, probably because of the additional absorption of carbon dioxide through the pleural cavity. Despite the presence of a peritoneo-pleural communication, surgery was successfully completed. We believe that gas under tension in the peritoneal cavity dissected along tissue planes around the oesophagus opened up during surgery. Thus pneumomediastinum, subcutaneous emphysema and pneumothorax are definite risks associated with this new procedure.

Complications of laparoscopic surgery

As with all surgical procedures, prevention and proper patient selection is the key to avoid complications. High-risk patients should be clearly identified from the outset. Properly maintained equipment, along with a thorough working knowledge of all instrumentation is essential. An often overlooked but vital aspect of laparoscopy is the laparoscopy team, including anesthesia and nursing personnel. A final point: there is no substitute for experience in avoiding laparoscopic complications. A survey by Phillips et al. found the complication rate for physicians who had performed fewer than 100 laparoscopic procedures to be almost four times greater than surgeons with more experience. A survey of eight centers active in urologic laparoscopic surgery reported that 10-20 pelvic lymph node dissections were necessary before they felt comfortable and 25-50 cases before they were proficient with the procedure. Since the learning curve with laparoscopy is initially quite steep, urologists beginning to apply the technique should work closely with experienced laparoscopic surgeons.

Pneumopericardium associated with laparoscopy

This case report describes a rare but potentially serious complication of pneumopericardium occurring during diagnostic laparoscopy. Contributing factors and possible etiologies are discussed.

Insertion of the laparoscopic Trocar without the use of carbon dioxide gas

Nine-hundred-and-fourteen patients have undergone the single puncture Falope Ring laparoscopic tubal ligations in a community hospital without prior insufflation of carbon dioxide gas. Anesthesia time averaged 10.5 minutes, surgical procedure time averaged 8.1 minutes. The patients left the hospital in satisfactory condition in the afternoon of the procedure. The only complication was a failed ligation (0.1%). Two-week follow-up showed no untoward complications. Omission of carbon dioxide insufflation before Trocar insertion lowers complications such as nausea, emesis, and post-operative pain. Also, anesthesia and surgical times are reduced. None of the patients required intubation during anesthesia.

Laparoscopy

It has been the purpose of this presentation to detail a safe technique for performance of laparoscopy. Emphasis has also been placed on potentially serious complications and how they can be avoided. This procedure employs highly technical equipment, and the surgeon should have formal training in the technique. It is essential to have an in-depth knowledge of the use of optics, electrical principles, gas under pressure, and the physiologic changes that occur when carbon dioxide is placed in the abdominal cavity. Above all, the surgeon must adhere rigidly to guidelines for appropriate technique. Deviation will most assuredly result in complications and even death.

Laparoscopy in the diagnosis of blunt and penetrating injuries to the abdomen

Laparoscopy was evaluated in thirty-seven patients from a group of 132 consecutive patients who were treated for blunt or penetrating injury to the abdomen. A total of twenty-three patients underwent laparoscopy and laparotomy. The findings at laparotomy correlated with laparoscopy. Fourteen patients underwent laparoscopy only, and there were no proved false-negative results. Of the 132 patients considered for laparotomy, 118 underwent abdominal exploration. Laparotomy was considered unnecessary in twenty-five of the 118 patients (21 per cent) and in retrospect, laparoscopy could have identified in each patient the presence of a minor injury or no injury at all. Laparoscopy is a useful method for evaluating blunt and penetrating injuries to the abdomen in selected patients.