Bilateral pneumothorax and surgical emphysema associated with laparoscopic cholecystectomy

Detection and Management of Intraoperative Pneumothorax during Laparoscopic Cholecystectomy

Intraoperative pneumothorax is a rare but potentially lethal complication during general anesthesia. History of lung disease, barotrauma, and laparoscopic surgery increase the risk of developing intraoperative pneumothorax. The diagnosis during surgery could be difficult because the signs are often nonspecific. We report a case of a middle-aged gentleman who developed right pneumothorax during an elective laparoscopic cholecystectomy. The patient had no risk factors for adverse events during the preoperative assessment (ASA1). The patient underwent general anesthesia and was put on mechanical ventilation. The first signs of abnormality immediately after surgical port insertion were tachycardia and low oxygen saturation in addition to sings of airway obstruction. The diagnosis of pneumothorax was made clinically by chest auscultation and later confirmed by intraoperative chest radiograph. Supportive treatment was started immediately through halting the surgery and manually ventilating the patient using 100% oxygen. Definitive treatment was then done by inserting an intercostal tube. After stabilizing the patient, the surgery was completed; then, the patient was extubated and shifted to the surgical ward. Postoperative computed tomography (CT) scan was done and showed only minimal liver laceration. The patient was discharged after removing the intercostal tube and was stable at the follow-up visit. Therefore, it is important to have a high index of suspicion to early detect and treat such complication. In addition, good communication with the surgeon and use of available diagnostic tools will aid in the proper management of such cases.

Spontaneous resolution of massive right-sided pneumothorax occurring during laparoscopic cholecystectomy

Pneumothorax is a rare but potentially serious complication that can occur during laparoscopic surgery. We describe a case of a spontaneous massive right-sided pneumothorax that occurred during laparoscopic cholecystectomy, presumably because of escape of intraperitoneal carbon dioxide under pressure into the pleural cavity through a congenital defect in the diaphragm. During the procedure, arterial oxygen saturation decreased and clinical examination revealed signs of a right-sided pneumothorax. This was confirmed on chest x-ray in the immediate postoperative period. Since the patient was clinically stable without any signs of respiratory distress, a conservative approach was adopted. The patient remained on close clinical observation and continuous monitoring of arterial hemoglobin oxygen saturation by pulse oximetry and repeat chest x-rays and had an uneventful recovery with complete resolution of the pneumothorax 3 hours after surgery and without the need for thoracic aspiration or tube thoracostomy.

Spontaneous resolution of massive laparoscopy-associated pneumothorax: the case of the bulging diaphragm and review of the literature

A massive left-side pneumothorax was identified intraoperatively on the basis of bulging left hemidiaphragm toward the end of an uncomplicated laparoscopic Nissen fundoplication. There were no changes in ventilatory or hemodynamic parameters. The pneumothorax was observed, and nearly total spontaneous resolution occurred in the recovery room within 1 hour.

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.

The effect of laparoscopic cholecystectomy on respiratory compliance as determined by continuous spirometry

STUDY OBJECTIVE

To evaluate the effect of pneumoperitoneum on dynamic compliance during laparoscopic cholecystectomy with continuous spirometry.

DESIGN

Prospective, open clinical study with the patients serving as their own controls.

SETTING

Operating room at a university hospital.

PATIENTS

11 ASA status I and II patients scheduled for elective laparoscopic cholecystectomy.

INTERVENTIONS

Pneumoperitoneum up to an intraabdominal pressure of 12 mmHg was created with carbon dioxide (CO2) insufflation. Thereafter, the patients were placed in a position combining a head-up tilt with a left side down lateral tilt, for dissection of the gallbladder. Steady levels of anesthesia and neuromuscular block, as well as a constant tidal volume of ventilation, were maintained throughout the procedure.

MEASUREMENTS AND MAIN RESULTS

Airway pressures and respiratory volumes were continuously measured. Compliance was calculated by dividing expiratory tidal volume by end inspiratory pressure, and was displayed as a pressure-volume loop. After the creation of pneumoperitoneum, end-inspiratory airway pressure increased by 40%, and compliance decreased by 30%. These levels remained unchanged during surgery with the patient in a head-up and left side down lateral tilt position. After release of intraabdominal pressure, inspiratory airway pressure and compliance returned to control levels. The pressure-volume loop sloped to the right and its horizontal diameter was elongated during pneumoperitoneum. The new configuration was maintained until the loop returned to the control shape after evacuation of the pneumoperitoneum.

CONCLUSIONS

Increased intraabdominal pressure during laparoscopic cholecystectomy causes a significant, but fully reversible, decrease in dynamic compliance. On-line spirometry with a graphic display of the pressure-volume loop facilitates the immediate discovery of these alterations.

Acute ventilatory complications during laparoscopic upper abdominal surgery

PURPOSE

This article examines and summarizes the published reports dealing with subcutaneous emphysema, pneumothorax and carbon dioxide (CO2) embolism during laparoscopic upper abdominal surgery. The purpose is to describe the expected clinical picture, the differential diagnosis and the management of these complications.

SOURCE

The information was obtained from a Medline literature search and the annual meeting supplements of Anesthesiology, Anesth Analg, Br J Anaesth and Can J Anaesth.

PRINCIPAL FINDINGS

An abrupt increase in PETCO2 is the first sign of subcutaneous emphysema and of pneumothorax. Desaturation and increased airway pressure occur with pneumothorax, but not with subcutaneous emphysema alone. Desaturation and increased airway pressure also occur with bronchial intubation. The preliminary diagnosis is made by verifying the position of the tube, examination of the patient for swelling and crepitus and auscultation for air entry. Chest radiography and paracentesis confirm the diagnosis of pneumothorax, which frequently occurs with subcutaneous emphysema but is rarely of the tension type. Pulmonary embolism due to CO2 during LUAS has not been reported, but the available data suggest that small, haemodynamically inconsequential CO2 embolism occurs without change in PETCO2. Massive embolism is possible and will markedly decrease PETCO2, arterial O2 saturation (SpO2) and blood pressure.

CONCLUSION

The immediate recognition of the three complications requires continuous monitoring of PETCO2, arterial saturation, airway pressure, and an index of pulmonary compliance.

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.

Bilateral pneumothorax, an unusual complication of laparoscopic surgery

Even though there are few complications with endoscopic surgery, some are life threatening. Pneumothorax is among these complications. Timely recognition and rapid diagnosis is essential. This is a case of a routine laparoscopy that was complicated by bilateral pneumothorax, and its diagnosis and treatment.