Carbon dioxide pneumothorax treatment with positive end-expiratory pressure

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.

Carbon dioxide pneumothorax occurring during laparoscopy-assisted gastrectomy due to a congenital diaphragmatic defect: a case report

During laparoscopic surgery, carbon dioxide (CO2) pneumothorax can develop due to a congenital defect in the diaphragm. We present a case of a spontaneous massive left-sided pneumothorax that occurred during laparoscopy-assisted gastrectomy, because of an escape of intraperitoneal CO2 gas, under pressure, into the pleural cavity through a congenital defect in the esophageal hiatus of the left diaphragm. This was confirmed on intraoperative chest radiography and laparoscopic inspection. This CO2 pneumothorax caused tolerable hemodynamic and respiratory consequences, and was rapidly reversible after release of the pneumoperitoneum. Thus, a conservative approach was adopted, and the remainder of the surgery was completed, laparoscopically. Due to the high solubility of CO2 gas and the extra-pulmonary mechanism, CO2 pneumothorax with otherwise hemodynamically stable conditions can be managed by conservative modalities, avoiding unnecessary chest tube insertion or conversion to an open procedure.

Surgical Tension Pneumothorax during Laparoscopic Repair of Massive Hiatus Hernia: A Different Situation Requiring Different Management

During laparoscopic repair of massive hiatus hernia, surgical dissection can breach the parietal pleura allowing insufflating carbon dioxide to rapidly expand the pleural space, causing a tension pneumothorax. This extrapulmonary pneumothorax involves no damage to the lung parenchyma. Its rapid resolution is aided by the high solubility of carbon dioxide and it will not refill once the procedure is completed. In this series of 50 massive hiatus hernia repairs the incidence of pneumothorax was 22% (11/50), with two of these being bilateral. Cardiovascular compromise occurred in 91% of those (10/11). The aetiology, pathophysiology and management of this intraoperative capnothorax differ significantly from that of a pneumothorax secondary to lung trauma or occurring during other types of laparoscopy. Understanding the relevant pleural anatomy and pathophysiology of this condition allowed conservative management in all cases and avoided the need for chest drains, open surgery or abandonment of the procedure.