Detection and Management of Intraoperative Pneumothorax during Laparoscopic Cholecystectomy

Abstract

Intraoperative pneumothorax is a rare but potentially lethal complication during general anesthesia. History of lung disease, barotrauma, and laparoscopic surgery increase the risk of developing intraoperative pneumothorax. The diagnosis during surgery could be difficult because the signs are often nonspecific. We report a case of a middle-aged gentleman who developed right pneumothorax during an elective laparoscopic cholecystectomy. The patient had no risk factors for adverse events during the preoperative assessment (ASA1). The patient underwent general anesthesia and was put on mechanical ventilation. The first signs of abnormality immediately after surgical port insertion were tachycardia and low oxygen saturation in addition to sings of airway obstruction. The diagnosis of pneumothorax was made clinically by chest auscultation and later confirmed by intraoperative chest radiograph. Supportive treatment was started immediately through halting the surgery and manually ventilating the patient using 100% oxygen. Definitive treatment was then done by inserting an intercostal tube. After stabilizing the patient, the surgery was completed; then, the patient was extubated and shifted to the surgical ward. Postoperative computed tomography (CT) scan was done and showed only minimal liver laceration. The patient was discharged after removing the intercostal tube and was stable at the follow-up visit. Therefore, it is important to have a high index of suspicion to early detect and treat such complication. In addition, good communication with the surgeon and use of available diagnostic tools will aid in the proper management of such cases.

Intraoperative transthoracic ultrasound in the differential diagnosis of small hepatectomy-induced pneumothorax

“…When the collapsed lung is contact with the chest wall during the inspiratory phase, the lung sliding sigh id visible, and when it leaves the chest wall in the expiratory phase, the lung sliding sign is no longer visible. The junction between the sliding lung and absent sliding is called the "lung point", a speci c sign of pneumothorax 23 .…”

“…It is widely believed that after the occurrence of pneumothorax, su cient oxygen supply should be maintained rst, and even pure oxygen ventilation can be considered to restore the collapsed lung function as far as possible 23 . Positive end-expiratory pressure ventilation mode can be applied to avoid hypoxia and serious hemodynamic uctuations.…”

Unexpected Tension Pneumothorax Developed during Anesthetic Induction Aggravated by Positive Pressure Ventilation: A Case Report

“…Factors associated with the development of pneumothorax include trauma and patient’s underlying pulmonary diseases, such as asthma, COPD, and emphysematous bullae which are vulnerable to rupture due to positive pressure ventilation [ 5 , 6 , 7 ]. Additionally, iatrogenic factors, including surgical and anesthetic procedures, such as pneumoperitoneum for laparoscopic procedures, CVC insertion, regional blocks adjacent to the pleura, and incorrect endotracheal intubation can also contribute to its occurrence [ 2 , 5 , 8 ]. In our case, there were no factors relating to pneumothorax other than the CVC insertion and positive pressure ventilation.…”

Paraplegia after Hypotension with Pneumothorax Episode during Thoracic Spine Tumor Surgery

“…The other possible reason may be primary lung lesion and prone position; both of them increased the aveolar positive end-expiratory pressure (PEEP) and induced pneumothorax. Intraoperative pneumothorax is a rare situation, but sometimes, it can potentially be life threatening [ 12 ]. The presence of emphysematous bullae or smaller blebs is a situation in which pneumothorax develops with positive pressure ventilation due to bullae or blebs rupture.…”