Pneumothorax – A Rare Complication Of Laparosocpic Total Extraperitoneal Hernia Repair.

Vol 1 | Issue 1 | July-Sep 2015 | page:24-25 | Rege Sameer[1], Arora Amandeep[1], Surpam S[1], Kotak N[2], Patel Rd[2].


Authors : Rege Sameer[1], Arora Amandeep[1], Surpam S[1], Kotak N[2], Patel Rd[2].

[1] Department of General Surgery, Seth GS Medical College & KEM Hospital, Mumbai-12.
[2] Department of Anaesthesiology, Seth GS Medical College & KEM Hospital, Mumbai-12.

Address of Correspondence
Dr Sameer Ashok Rege
Department of Surgery,
Seth GS Medical College & KEM Hospital, parel, Mumbai-12
Email: samrege@yahoo.com


Abstract

Introduction: A 45 year old male patient undergoing bilateral Total extraperitoneal inguinal hernia repair developed hypotension with a fall in oxygen saturation about 20 minutes into the procedure. He was diagnosed to have right sided pneumothorax which was treated with an intercostal drainage tube. The patient had no surgical emphysema or pneumoperitoneum. Patient had an uneventful recovery.
Keywords: Pneumothorax, total extraperitoneal repair.


Introduction

Laparoscopic inguinal hernia repair is being performed with increasing frequency. Decreased postoperative patient pain and quicker return to normal activity are potential advantages associated with laparoscopic hernia repair. Also, TEP repair is being preferred to the transabdominal preperitoneal (TAPP) repair. (1,2) Pneumothorax, pneumomediastinum and subcutaneous emphysema are unexpected complications of extraperitoneal hernia repair. Longer duration of the procedure with high preperitoneal insufflations pressures have been proposed to be the possible causes of the complication.

Case report

A 45 year old male with bilateral inguinal hernia with no comorbid conditions was admitted for laparoscopic extraperitoneal repair. Patient had an uneventful intubation with 8.5F endotracheal tube with equal air entry on both sides. In supine position with Trendelenburg’s position, the extraperitoneal space was accessed with an open technique with 10mm port in sub-umbilical area. The CO2 pressure was kept at 12 mmHg and the flow rate was kept at 3 lit/min. Another 5mm port was place in the midline and space was created on the right side and 5mm port was placed in right lumbar region. Patient had hypotension of 88 mmHg systolic with normal eTCO2 and increased ventilator peak airway pressure. SaO2% dropped to 88%. On auscultation, there was no air entry on the right side. A needle thoracostomy was done with a gush of air. Patient was hyperventilated without nitrous oxide, and the vitals of the patient improved with SaO2% to 100%. Diagnosis of pneumothorax was made and intercostal tube was placed in 5th intercostal space.The procedure was completed after lowering the CO2 pressure to 10 mmHg in next 25 mins. There was no major bleeding or peritoneal breach or surgical emphysema noted on abdominal or the chest wall. Post procedure, patient was extubated, however was observed in intensive care unit for 8 hours.
The intercostal drainage had no air leak in postoperative period and was removed on day 2 and patient was discharged on day 3. An immediate post op chest X-ray had showed a small (<1cm) pneumothorax and no pneumoperitoneum which was consistent with no peritoneal breach during the surgery.

Discussion

Laparoscopic TEP repair is a favoured procedure for bilateral and recurrent inguinal hernias due to low recurrence rate, a reduced risk of intra-abdominal infection or contamination, and damage to the intra-abdominal organs and adhesions, as compared with laparoscopic transabdominal preperitoneal hernia repair or an open procedure. It also causes less postoperative pain with early return to activity.(1,2) Common intraoperative complications of TEP include surgical emphysema, pneumoperitoneum, pneumoscrotum. In general anaesthesia, patients can develop pneumothorax due to barotrauma or ruptured emphysematous bullae or injury to the trachea or any central line procedures and should be ruled out. Pnuemothorax though reported ,is a rare complication encountered during TEP as the CO2 insufflation is limited only to the extraperitoneal space (3-7).  Though the dissection is in the extraperitoneal space, various theories have been proposed. Ferzli et al have suggested the entry of CO2 from the retroperitoneal space to pleural space and the neck, which can lead to pnuemothorax and surgical emphysema in the neck (3). Shim et al have reported pneumothorax during retroperitoneal nephrectomy with high Co2 pressures of 15mmHg (8). However in our patient, the pressure was maintained to 12 mmHg with flow rate of 3 lit/min. CO2 traversing the congenital diaphragmatic defects or along the aortic or esophageal defects or Bochdaleck’s foramen after an accidental peritoneal breach has been proposed by Browne et al (5), however our patient did not have any pneumoperitoneum.
Pneumothorax is usually diagnosed with respiratory distress and breathlessness which is difficult to diagnose in an intubated patient. However, sudden tachycardia, hypotension, hypercapnia with increased ventilatory pressure and decreased air entry on the side may be helpful in diagnosing pneumothorax intraoperatively.  Intercostal drainage is not mandatory, but a safer approach since, if the vitals are stable, the CO2 gets diffused within 60 minutes from the tissues. With suspicion of the diagnosis, the CO2 insufflation should be stopped. The nitrous oxide ventilation should be discontinued with hyperventilation. If vitals are maintained the procedure may be continued with decreased CO2 pressures of 10 mmhg. Most of the patients may not require postoperative ventilation, however Joris et al have suggested elective ventilation with elevated positive end expiratory pressure for intraoperative pneumothorax than a tube thoracostomy (9). The actual incidence of this complication is unknown because postoperative chest radiographs are not and should not be routine after any type of hernia repair. In the situation in which an asymptomatic patient is found to have a pneumothorax, deviation from routine postoperative care is not necessary. However in the symptomatic patient, observation and appropriate monitoring is strongly recommended. Once the condition is diagnosed intraoperatively, CO2 insufflation should be stopped or reduced. Nitric oxide should be discontinued and hyperventilation should be performed. Placement of an intercostals drainage tube is not necessary unless the patient becomes hemodynamically unstable or if the respiration is compromised (10). Otherwise careful monitoring is all that is necessary.CO2 is spontaneously lost in most cases in 30 to 60 minutes following the release of the gas (11).

Conclusion

Pneumothorax is a rare complication of laparoscopic TEP repair, which potentially prolongs hospital stay and thereby increases total costs. The incidence of this complication is only going to increase in the future. Shorter operative duration and lower (10mm Hg) insufflations pressure can help prevent this. We should be aware of this complication to recognize it early in case of an unexplained hemodynamic and respiratory collapse during the surgery. Prompt diagnosis and suitable management can prevent any serious problems.


References

1. Ramshaw BJ, Tucker JG, Conner T, Mason EM, Duncan TD, Lucas GW. A comparison of the approaches to laparoscopic herniorrhaphy. SurgEndosc. 1996;10:29–32.
2. Kald A, Anderberg B, Smedh K, Karlsson M. Transperitoneal or totally extraperitoneal approach in laparoscopic hernia repair: results of 491 consecutive herniorrhaphies. SurgLaparoscEndosc. 1997;7:86–89.
3. Ferzli GS, Kiel T, Hurwitz JB, Davidson P, Piperno B, Fiorillo MA, et al. Pneumothorax as a complication of laparoscopic inguinal hernia repair. SurgEndosc. 1997;11:152–153.
4. Harkin CP, Sommerhaug EW, Mayer KL. An unexpected complication during laparoscopic herniorrhaphy. AnesthAnalg. 1999;89:1576–1578.
5. Browne J, Murphy D, Shorten G. Pneumomediastinum, pneumothorax and subcutaneous emphysema complicating MIS herniorrhaphy. Can J Anaesth. 2000;47:69–72.
6. Bartelmaos T, Blanc R, De Claviere G, Benhamou D. Delayed pneumomediastinum and pneumothorax complicating laparoscopic extraperitoneal inguinal hernia repair. J ClinAnesth. 2005;17:209–212.
7. Lo CH, Trotter D, GrossbergP.Unusual complications of laparoscopic totally extraperitoneal inguinal hernia repair. ANZ J Surg. 2005 Oct;75(10):917-9
8. Shim HS, Park SH, Ryu DH, Kim IK, Shin MK. Pneumothorax during retroperitoneal laparoscopic nephrectomy. Korean J Anesthesiol. 2005;48:324–327.
9. Joris JL, Chiche JD, Lamy ML. Pneumothorax during laparoscopic fundoplication: diagnosis and treatment with positive end-expiratory pressure. Anesth Analg. 1995 Nov;81(5):993-1000.
10. Pneumothorax during laparoscopic totally extraperitoneal inguinalherniarepair -A case report-Hye Young Kim, Tae-Yop Kim, Kyu Chang Lee, Myeong Jong Lee, Seong-Hyop Kim, Jong Min Bahn, Eun Kyung Choi, JiYeon Kim. Korean J Anesthesiol. 2010 May; 58(5): 490–494.
11.Togal T, Gulhas N, Cicek M, Teksan H, Ersoy O. Carbon dioxide pneumothorax during laparoscopic surgery. SurgEndosc. 2002;16:1242.


How to Cite this Article: Rege S, Arora A, Surpam S, Kotak N, Patel Rd. Pneumothorax – A Rare Complication Of Laparosocpic Total Extraperitoneal  Hernia  Repair. International Journal of Surgical Cases 2015 July-Sep;1(1): 24-25.          

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