BackgroundLaparoscopy is commonly used for a variety of surgical procedures. The benefits of laparoscopy compared to open surgery include decreased post-operative pain, smaller incisions, and reduced hospital length of stay.... [ view full abstract ]
Background
Laparoscopy is commonly used for a variety of surgical procedures. The benefits of laparoscopy compared to open surgery include decreased post-operative pain, smaller incisions, and reduced hospital length of stay. Laparoscopy is enabled by insufflation of carbon dioxide into the peritoneal cavity producing pneumoperitoneum. Common complications of pneumoperitoneum include hypercapnia, decreased venous return, bradycardia, and subcutaneous emphysema. Here, we present an uncommon complication of laparoscopic surgery and its management.
Case description
A 68 year old, 5’10”, 66kg male was scheduled for elective Laparoscopic Diverticulectomy and Heller Myotomy for diagnosed achalasia and epiphrenic diverticulum. Abdominal insufflation occurred uneventfully following induction of general anesthesia. Forty-five minutes into the procedure, measured EtCO2 acutely decreased from 35 to 23 mm Hg with coinciding drop in BP from 130/70 to 47/29 and increased peak inspiratory pressure (PIP) from 22 to 31 cm H2O. The surgeons noted a large tear in the right diaphragm that they would be unable to repair. Tension capnothorax was presumed. Hemodynamic stability was achieved with Epinephrine 100 mcg, Phenylephrine 500 mcg, and 500 mL of 5% Albumin. A recruitment maneuver was performed. Within three minutes after the event, EtCO2 and blood pressure returned to baseline. PIP remained stably elevated. A recruitment maneuver was again performed prior to emergence, and oxygen saturation was 100% at that time. The patient was extubated in the OR. In the PACU, the patient complained of chest pain with an oxygen desaturation to 92% but stable hemodynamics. Chest X-ray in the PACU was notable for very large right pneumothorax with collapsed RUL. Given the patient’s stable hemodynamics and under the clinical assumption that the patient’s pneumothorax was secondary to abdominal insufflation, the patient was treated expectantly. His symptoms completely resolved within 3 hours after emergence. Serial chest x-rays revealed complete re-expansion of the right lung over the next day. He was discharged home on POD#2.
Discussion
Pneumothorax secondary to carbon dioxide insufflation (capnothorax), has been recognized as a complication of laparoscopic procedures. While perioperative conservative therapy is advocated for recognized capnothorax without hemodynamic compromise, more uncertainty exists when determining the appropriate treatment for tension capnothorax.
Capnothorax during laparoscopy involves a diaphragmatic defect, congenital or iatrogenic, through which pressurized CO2 flows into the pleural space. If a large enough defect allows a very rapid increase in intrapleural pressure, mediastinal shift may occur and cause hemodynamic compromise. Classically, treatment of acute tension pneumothorax involves needle decompression with subsequent chest tube placement. However, these interventions carry inherent risks. In patients with a suspected capnothorax, overcoming the intrapleural pressure through recruitment maneuvers may shift the intrapleural pressure gradient back into the abdomen and relieve hemodynamic compromise. Because CO2 is rapidly reabsorbed by the body, conservative management may be warranted post-operatively. In contrast to patients with pneumothorax, the clinician may choose to manage patients with capnothorax non-invasively throughout the perioperative period.
