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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
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Abstract |
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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.
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Introduction |
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Two techniques using laparoscopy are described, a transabdominal preperitoneal approach3 or an intraperitoneal approach using an on-lay mesh over the defect.4
The patient described in this case report had an extraperitoneal "laparoscopic" herniorrhaphy.5 When this technique is used, laparoscopy is not performed and the peritoneum remains intact. A "pneumoextraperitoneum" is established using CO2 gas. Although technically more difficult, this, in theory, avoids the complications associated with laparoscopy.5
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Case history |
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The surgical procedure was prolonged, lasting 195 min. The patient was hemodynamically stable throughout. There was no decrease in SpO2 and PETCO2 was maintained < 40 mmHg. Peak inflation airway pressures were consistently < 25mmHg and did not increase during the case.
Prior to emergence from anesthesia, and reversal of neuromuscular blockade, the surgical drapes were removed. Extensive subcutaneous emphysema involving the scrotum, abdomen, thorax and neck was noted. There were no abnormal clinical signs on chest examination. A chest radiograph (Figure 1
) revealed a pneumomediastinum and left sided pneumothorax. A 24 French gauge intercostal tube was inserted in the left 5th intercostal space, midaxillary line and connected to an underwater seal drain. Sedation and positive pressure ventilation were continued overnight to permit resolution of the surgical emphysema, pneumomediastinum and pneumothorax and to avoid airway compromise.
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) revealed resolution of the pneumothorax and a decrease in the amount of mediastinal air. The surgical emphysema had largely resolved. There was an audible leak around the ET tube. The trachea was extubated and the intercostal tube removed. Subsequent recovery was uneventful and he was discharged from hospital the following morning.
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Discussion |
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There are many possible routes for gas to enter the thoracic cavity during pneumoperitoneum.6,9,10 Postulated sites for this to occur are via the pleuroperitoneal hiatus (Foramen of Bochdalek), around the esophageal and aortic hiatus, via any congenital diaphragmatic defect (e.g. Foramen of Morgagni ). In addition, any procedure that can damage the falciform ligament (e.g. during insertion of a Veress needle), may provide a route for gas or fluid to enter the thoracic cavity.
Other causes of pneumothorax unrelated to the laparoscopic technique should be borne in mind. It may result from barotrauma, injury to the trachea during intubation, spontaneous rupture of a congenital bulla or as a complication of central venous line insertion. In this case it is unlikely that any of these factors contributed to the development of pneumothorax or pneumomediastinum.
As a pneumoperitoneum was not used in this case the routes outlined for gas to traverse the diaphragm should not have been available. The peritoneum may have been inadvertently breached. This has been described with the extraperitoneal approach and can cause potential complications including bladder and bowel injury intraoperatively, and postoperative adhesions.5
The duration of the surgical procedure was long, 195 min. The average duration of the procedure for unilateral herniorrhaphy in one series was 111 min5. Technical difficulties causing an increased operation time may have resulted from leakage of gas into the peritoneum. However, the duration of the procedure has not been shown to affect the diffusion of CO2 into the body.12
Alternatively, the peritoneum may not have been breached and the gas may have tracked retroperitoneally, causing the pneumomediastinum and pneumothorax.13 Three cases have been described 14 in which patients undergoing laparoscopic herniorrhaphy (TAPP approach) developed subcutaneous emphysema of the neck and pharyngeal emphysema. The authors postulated that the myopectineal dissection could have provided a route for carbon dioxide to track retroperitoneally and access the neck. The scrotal emphysema could be explained by gas tracking along Scarpa's fascia.
The role of nitrous oxide in expanding pneumothoraces is well described. This is due to its water solubility relative to that of nitrogen (blood/gas coefficient 0.47 and 0.15 respectively). For this reason it diffuses into a closed gas space 30 times more rapidly than nitrogen diffuses out.
Using nitrous oxide 70% the volume of a pneumothorax may double in 10 min.15 It is unclear if nitrous oxide can be implicated in expanding a pneumothorax caused by carbon dioxide gas.11 Graham's law of diffusion states that the rate at which different gases diffuse is inversely proportional to the square roots of their molecular masses, other factors being kept constant.16 As nitrous oxide and carbon dioxide have the same molecular mass, it is likely that the use of nitrous oxide would not expand a carbon dioxide containing closed space. The rapid resolution of the clinical and radiological findings is highly suggestive of a capnothorax and capnomediastinum.
This case illustrates the possibility of pneumothorax developing during videoscopic herniorrhaphy, even if a pneumoperitoneum is not employed. The anesthesiologist should consider this possibility, even if the intraoperative course is unremarkable and, in particular, if the patient develops subcutaneous emphysema. The fact that such a potentially serious complication can arise may raise questions as to the validity of this technique over the open technique, particularly in unilateral, non-complicated hernia repairs. In an analytical cohort study,2 Dion suggested that the increased cost of the laparoscopic repair might not be justified by the advantages of the technique, particularly for primary, unilateral herniae. Anesthesiologists caring for patients undergoing videoscopic herniorrhaphy should be aware of the potential development of pneumomediastinum and pneumothorax, whether deliberate creation of a pneumoperitoneum is planned or not.
Accepted for publication September 10, 1999.
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References |
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2 Dion Y-M. Laparoscopic inguinal herniorrhaphy: appraisal of a cohort study. Can J Surg 1996; 39: 229–32.[Medline]
3 Litwin DEM, Pham QN, Oleniuk FH, Kluftinger AM, Rossi L. Symposium on the management of inguinal hernias. 3. Laparoscopic groin hernia surgery: The TAPP procedure. Can J Surg 1997; 40: 192–98.[Medline]
4 Winchester DJ, Dawes LG, Modelski DD, et al. Laparoscopic inguinal hernia repair. A preliminary experience. Arch Surg 1993; 128: 781–86.[Abstract]
5 Smith CD, Tiao G, Beebe T. Intraoperative events common to videoscopic preperitoneal mesh inguinal herniorrhaphy. Am J Surg 1997; 174: 403–5.[Medline]
6 Prystowsky JB, Jericho BG, Epstein HM. Spontaneous bilateral pneumothorax – complication of laparoscopic cholecystectomy. Surgery 1993; 114: 988–92.[Medline]
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Cunningham AJ, Brull SJ. Laparoscopic cholecystectomy: anesthetic implications. Anesth Analg 1993; 76: 1120–33.
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10 Doctor NH, Hussain Z. Bilateral pneumothorax associated with laparoscopy. A case report of a rare hazard and review of literature. Anaesthesia 1973; 28: 75–81.[Medline]
11 Hasel R, Arora SK, Hickey DR. Intraoperative complications of laparoscopic cholecystectomy. Can J Anaesth 1993; 40: 459–64.
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Mullet CE, Viale JP, Sagnard PE, et al. Pulmonary CO2 elimination during surgical procedures using intra- or extraperitoneal CO2 insufflation. Anesth Analg 1993; 76: 622–6.
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Wahba RWM, Tessler MJ, Kleiman SJ. Acute ventilatory complications during laparoscopic upper abdominal surgery. Can J Anaesth 1996; 43: 77–83.
14 Chien GL, Soifer BE. Pharyngeal emphysema with airway obstruction as a consequence of laparoscopic inguinal herniorrhaphy. Anesth Analg 1995; 80: 201–3.[Medline]
15 Eger EI II, Saidman LJ. Hazards of nitrous oxide anesthesia in bowel obstruction and pneumothorax. Anesthesiology 1965; 26: 61–6.[Medline]
16 Strickland D. Physical Principles Part 1: Mechanical Quantities. In: Scurr C, Feldman S (Eds.). Scientific Foundations of Anaesthesia, 3rd ed. London: William Heinemann, 1982: 90–2.
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