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Pneumomediastinum, pneumothorax and subcutaneous emphysema complicating MIS herniorrhaphy

From the Department of Anaesthesia and Intensive Care Medicine, Cork University Hospital and University College Cork, Wilton, Cork, Ireland.

Address correspondence to:Dr. Deirdre Murphy, Phone: 353-021-922135; Fax: 353-021-343307

Purpose: Videoscopic herniorrhaphy is being performed more frequently with advantages claimed over the conventional open approach. This clinical report describes a pneumothorax, pneumomediastinum and subcutaneous emphysema occurring at the end of an extraperitoneal videoscopic herniorrhaphy.

Clinical Features: A 25 yr old ASA 1 man presented for elective extraperitoneal videoscopic hernia repair. Following intravenous induction with fentanyl, midazolam and propofol a balanced anesthetic technique using enflurane in N₂O and O₂ was used. Apart from a prolonged operating time (195 min), the procedure and anesthetic was uneventful.

At the conclusion of the operation, prior to reversal of neuromuscular blockade extensive subcutaneous emphysema was noted on removal of the surgical drapes. Chest radiography revealed a pneumomediastinum and pneumothorax. A 25 FG intercostal tube was inserted and connected to an underwater seal drain. Sedation and positive pressure ventilation was maintained overnight to permit resolution and avoid airway compromise. The clinical and radiological features had resolved by the next morning and the patient's trachea was extubated. His subsequent recovery was uneventful.

Conclusion: Pneumothorax and pneumomediastinum are well recognised complications of laparoscopic techniques but have not been described following extraperitoneal herniorrhaphy. In this report we postulate possible mechanisms which may have contributed to their development, including inadvertent breach of the peritoneum and leakage of gas around the diaphragmatic herniae or tracking of gas retroperitoneally. The case alerts us to the possibility of this complication occurring in patients undergoing videoscopic herniorrhaphy.