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

Preoperative bullae and subsequent pneumothorax in 6605 patients who underwent robotic prostatectomy

PURPOSE

Robotic prostatectomy is the most common surgical approach for treating prostate cancer. Patients undergoing robotic prostatectomy may have bullae, which may rupture leading to pneumothorax. We evaluated the incidence of pneumothorax due to preoperative bullae rupture in robotic prostatectomy.

METHODS

A large retrospective study of patients who underwent robotic prostatectomy between 2009 and 2021 was conducted. Bullae were detected using chest computed tomography. Pneumothorax was detected using a chest X-ray. The primary outcome was the incidence of pneumothorax due to bullae rupture. Secondary outcomes were the prevalence of preoperative bullae and the evaluation of postoperative outcomes, including length of hospital stay, intensive care unit admission rate, and prolonged intensive care unit stay (> 2 days).

RESULTS

A total of 6605 patients were included. The prevalence of preoperative bullae was 3.0% (196/6,605). There was no incidence of pneumothorax due to bullae rupture. No significant difference in the incidences of pneumothorax between patients with and without bullae (0/196 vs. 2/6,409, P > 0.999) was observed. In addition, length of hospital stay, intensive care unit admission rate, and prolonged intensive care unit stay were not significantly different between the two groups. Kaplan-Meier analysis showed that there was no significant difference in lengths of hospital stay between the two groups (log-rank test, P > 0.999).

CONCLUSION

In our cohort, there was no incidence of pneumothorax following robotic prostatectomy in patients with preoperative bullae. This result could help in the management of patients with prostate cancer with bullae.

Pneumothorax during retroperitoneal laparoscopic partial nephrectomy in a lupus nephritis patient: A case report

BACKGROUND

Downgrading target treatment and laparoscopic partial nephrectomy have become increasingly popular in patients with renal cell carcinomas. Rare as it is, pneumothorax is one of the most severe intraoperative complications which needs immediate recognition. On the other hand, as a rheumatological disease, lupus nephritis requires a long period of hormone therapy. Cases of pneumothorax in hormone-consuming renal cancer patients are even fewer.

CASE SUMMARY

A 39-year-old woman was admitted to our department to take a laparoscopic partial nephrectomy. The patient had a medical history of lupus nephritis and renal clear cell carcinoma with hormone and target treatment. Her blood oxygen saturation dropped to 92% during the operation, and pneumothorax was detected by ultrasound. O₂ inhalation and lung dilation were performed. Her vital signs were monitored closely throughout the operation. The operation was accomplished, and she regained consciousness smoothly. A postoperative bedside chest X-ray was conducted after she was transferred to the urosurgery ward, while no evidence of further pneumothorax or lib injury was observed.

CONCLUSION

Pneumothorax is a severe complication in laparoscopic or robotic-assisted laparoscopic operations, especially in retroperitoneal ones. It is easily neglected unless the injury of the diaphragm is found. Low insufflation pressure and shorter operation time are necessary for patients with a history of long-term hormone consumption or chronic immune system disease.

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.

Spontaneous pneumothorax in two dogs undergoing combined laparoscopic ovariectomy and total laparoscopic gastropexy

Two dogs underwent a combined laparoscopic ovariectomy and total laparoscopic gastropexy. The intra-abdominal pressure and pulmonary compliance decreased, but the peak airway pressure increased at 20 min after the start of gastropexy with intracorporeal suturing. Right chest auscultation and percussion revealed reduced breath sounds and hyper-resonance. No abnormalities in the functioning of the instruments or diaphragmatic defects were detected. The tidal volume was reduced and a positive end-expiratory pressure of 5 cmH₂O was applied. The right chest of the two dogs was drained off: 950 mL (case 1) and 250 mL (case 2) of gas. After thoracentesis, the pulmonary compliance improved and surgery was completed successfully. The postoperative chest radiographs highlighted the residual right pneumothorax.

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.