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CASE REPORT
Year : 2007  |  Volume : 51  |  Issue : 3  |  Page : 231-233  

Capnothorax during laparoscopic cholecystectomy


1 DA, DNB, Specialist, Department of Anaesthesia and Intensive Care, Maulana Azad Medical College, New Delhi - 110002, India
2 MD, Assistant Professor, Department of Anaesthesia and Intensive Care, Maulana Azad Medical College, New Delhi - 110002, India
3 MD, Professor, Department of Anaesthesia and Intensive Care, Maulana Azad Medical College, New Delhi - 110002, India
4 MD, Senior Resident, Department of Anaesthesia and Intensive Care, Maulana Azad Medical College, New Delhi - 110002, India
5 PG Student, Department of Anaesthesia and Intensive Care, Maulana Azad Medical College, New Delhi - 110002, India
6 DA, Specialist, Department of Anaesthesia and Intensive Care, Maulana Azad Medical College, New Delhi - 110002, India

Date of Acceptance02-Mar-2007
Date of Web Publication20-Mar-2010

Correspondence Address:
Poonam Bhadoria
4LF, Todarmal Square, Bharakhamba Road, New Delhi - 110001
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Source of Support: None, Conflict of Interest: None


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Laparoscopic procedures are becoming increasingly widespread as more and more surgical procedures are becoming amenable to laparoscopic repairs. As the spectrum of the procedures widens, so are the likely complications. It is imperative for the discerning anaesthesiologists to be vigilant for the possible complications related to this technique.

Keywords: Laparoscopic cholecystectomy ; CO 2 insufflation, Pneumoperitoneum, Pneumothorax.


How to cite this article:
Manchanda G, Bhalotra AR, Bhadoria P, Jain A, Goyal P, Arya M. Capnothorax during laparoscopic cholecystectomy. Indian J Anaesth 2007;51:231-3

How to cite this URL:
Manchanda G, Bhalotra AR, Bhadoria P, Jain A, Goyal P, Arya M. Capnothorax during laparoscopic cholecystectomy. Indian J Anaesth [serial online] 2007 [cited 2019 May 19];51:231-3. Available from: http://www.ijaweb.org/text.asp?2007/51/3/231/61149


   Introduction Top


Over the last few decades, laparoscopy has become an indispensable tool for all types of surgeries and has evolved from a diagnostic modality to a method of per­forming complex surgical procedures. Laparoscopic chole­cystectomy is becoming popular and has largely replaced the open surgical procedures. The advantages claimed for laparoscopic techniques include less postoperative pain, reduced hospital stay, a good cosmetic result and decreased morbidity. [1] However, with its increasing popularity and uses, the number and variety of complications associated with laparoscopic procedures are likely to increase. The main complications seem to be related to the insufflation of car­bon dioxide gas. These include hypercarbia, subcutaneous emphysema, pneumothorax and pneumomediastinum. [2] Anaesthesiologists and surgeons should be aware of these complications and should be prepared to treat any haemodynamic and/or ventilatory problems.

We report a case of spontaneous right-sided capnothorax occurring during an otherwise uneventful laparoscopic cholecystectomy.


   Case report Top


Laparoscopic cholecystectomy was performed on a 23-year-old non-smoker female patient (ASA I, height 155cm, weight 43 kg). After induction of general anaes­thesia with pethidine and thiopentone, vecuronium was given to facilitate endotracheal intubation and the lungs were ven­tilated with 66% nitrous oxide and 0.5%-1% isoflurane in oxygen using an Ohmeda ventilator with a tidal volume of 450 ml at a rate of 12 breaths per minute. Chest inflation was adequate and equal and normal breath sounds were heard bilaterally. Neuromuscular block was maintained with intermittent doses of vecuronium and an oro-gastric tube was placed prior to creation of pneumoperitoneum.

Intraoperative monitoring included continuous elec­trocardiogram (ECG), heart rate (HR), noninvasive blood pressure (NIBP), arterial oxygen saturation by pulse oxim­etry (SpO2), end tidal carbon dioxide concentration (EtCO2), tidal volume, minute volume and airway pres­sures. After intubation, BP was 116/76 mmHg, HR 88/ min, EtCO2 35mmHg with SpO2 99% and airway pres­sure was 16cm of H2O.

With the patient in the supine position, a pneumoperi­toneum of 12 mmHg was established with CO2 using an electronic variable flow, pressure-controlled insufflator.

The patient was then placed in a 40-degree reverse Trendelenburg position with right side up. Minute ventila­tion was increased from 4.5L to 6L during CO2 pneumo­peritoneum to maintain EtCO2 at around 40 mm Hg. Despite the adjustment in minute ventilation EtCO2 increased to 48 mmHg towards the end of surgery. There was also a slight increase in peak inspiratory pressure (PIP) from 16 to 20 cm of H2 O. The patient's vital parameters remained within normal limits and SpO2 was around 96-97% at this time. The surgical procedure lasted for 110 minutes but was technically uneventful. At the end of surgery, the pa­tient was returned to the horizontal position and the abdo­men was desufflated. Residual neuromuscular blockade was antagonized and the patient's trachea was extubated.

Following extubation, despite good respiratory efforts SpO2 on room air was 88- 89%. Patient was given 100% oxygen by facemask at 4-5L/ min on which SpO2 increased to 99%. Decreased chest movements were then noticed on the right side. On auscultation air entry was found to be markedly reduced on the same side. A chest X-ray was done in the theatre, which revealed right-sided pneumotho­rax.

As the patient was fully conscious, haemodynamically stable and seemed comfortable, she was put on oxygen by ventimask with FiO2 0.5% at 4-5L/min and was shifted to the postoperative ward for further observation. The SpO2 gradually increased from 92% at FiO 2 0.5% to 96% over a period of 30 minutes. Air entry also improved over right chest.

After another one hour, bilateral air entry was equal and adequate. She was maintaining SpO2 99-100% on ventimask. A repeat chest X-ray was normal. The patient had an uneventful recovery and was discharged two days later by the surgical unit.


   Discussion Top


The incidence of pneumothorax/pneumomediastinum is 1.9% during any kind of laparoscopic surgery. However, the occurrence of a pneumothorax complicating laparoscopic cholecystectomy is very unusual. [2] Gas may enter the chest by a variety of routes. These include trauma to the diaphragm or falciform ligament, passage through congenital defects or foramina in the diaphragm or via a subperitoneal route. Pneumothorax, pneumomediastinum and surgical emphysema may also result from barotrauma or from rupture of an emphysematous bulla. [1]

Presence of congenital diaphragmatic defects pro­ducing a pleuroperitoneal communication is the most com­mon explanation. According to Meyer the communication of pleural and peritoneal cavities closes in the third month of gestation. [3] Diaphragm forms from the fusion of septum transversum, dorsal and ventral mesenteries and the pleuroperitoneal membrane. Improper fusion of these struc­tures or improper deposition of mesoderm at the points of union results in congenital weak points or defects in the diaphragm. [3] Opening of these pleuroperitoneal ducts re­sults mainly in right-sided pneumothorax. [4] Gas insufflation through a perforated falciform ligament has also been pro­posed to cause pneumothorax during laparoscopic chole­cystectomy by forcing gas into the mediastinum through the caval orifice of diaphragm. [5] A pneumothorax can also be due to rupture of preexisting bullae. Such a situation is more common in elderly chronic smoker patients with un­derlying chronic obstructive airway- disease. In this case there will be no increase in CO2 absorption and treatment required is different. Thoracocentesis is mandatory and PEEP must not be applied. [6]

A cephalad displacement of the diaphragm and ca­rina after creating pneumoperitoneum during laparoscopic cholecystectomy can lead to endobronchial intubation and collapse of contralateral lung. Right-sided endobronchial intubation is more common leading to left lung collapse. This complication results in decrease in SpO 2 associated with an increase in plateau airway pressure. [4] EtCO 2 how­ever may not rise markedly. Fibreoptic bronchoscopy can be done to rule out this complication. [7]

We have described a case of spontaneous unilateral carbon dioxide pneumothorax in a ASA grade 1 patient undergoing routine laparoscopic cholecystectomy. The first sign was a progressive increase in EtCO2 despite adjust­ments in minute ventilation. Aslight increase in airway pres­sures and decrease in SpO2 intraoperatively and inability to maintain SpO2 after extubation further support the diag­nosis. Lack of breath sounds on auscultation over the right side of thorax and the chest X-ray confirmed the diagnosis of a pneumothorax. During CO2 pneumoperitoneum, CO2 absorption and subsequently EtCO2 progressively increase and then plateau after 20-30 minutes. Any change in this value after its steady state is reached, suggests a compli­cation. [7] The initial increase in EtCO2 in this patient was probably only due to absorption of CO2 from subcutane­ous tissues but a later rapid increase in EtCO2 accompa­nied by increase in PIP indicated capnothorax.

If a potential pneumothorax is suspected towards the end of surgery, it may be managed conservatively since the gas is highly soluble in blood and thus gets quickly ab­sorbed from the pleural cavity after abdominal desufflation. [5],[6] The procedure may be allowed to continue after cessation of nitrous oxide with close observation of cardiovascular and respiratory parameters as the insertion of chest tube is not without complications and its insertion can compromise maintenance of pneumoperitoneum and hence laparoscopy. [7] However, if there is massive pneu­mothorax with haemodynamic instability, recognized in the beginning or middle of laparoscopic procedure, then the abdomen should be deflated while tube thoracostomy is performed. Once the chest tube is in satisfactory position, then the abdomen can be reinsufflated and the procedure can be continued if the patient remains stable. [3] In the pres­ence of a tension pneumothorax, standard therapeutic measures should be instituted including needle thoracos­tomy followed by placement of a chest tube. [3] Administra­tion of nitrous oxide has to be discontinued when pneu­mothorax occurs to prevent or correct hypoxemia and to prevent a volume increase of pneumothorax. [6]

Laparoscopy for general surgery often involves longer procedures, larger insufflated volumes, different sites and degrees of dissection, different patient positions, older pa­tients and often more inexperienced laparoscopists. [1] With this in mind all patients for general surgical laparoscopy should be carefully monitored. Pneumothorax remains a rare and occasionally reported complication. It should be remembered that capnothorax can occur even without pulmonary or pleural trauma. Factors that predispose to development of pneumothorax include high CO2 insuffla­tion pressure (15 mm of Hg) and operative time greater than 200 minutes. [2],[8] Pneumothorax should be considered in the presence of hypercarbia, increased airway pressures, oxygen desaturation or any haemodynamic compromise. [3] A careful monitoring of EtCO2 , arterial oxygen saturation, airway pressures, pulse rate, blood pressure, ECG and in­flation pressure along with close clinical scrutiny can lead to an immediate recognition of this complication, early treat­ment and uneventful recovery of the patient.

 
   References Top

1.Woolner DE, Johnson DM. Bilateral pneumothorax and surgical emphysema associated with laparoscopic cholecystectomy. Anaesthesia and Intensive care 1993 ; 21: 108-110.  Back to cited text no. 1
    
2.Murdock CM, Wolff AJ, Geem TV. Risk factors for hypercarbia, subcutaneous emphysema, pneumothorax and pneumomediasti­num during laparoscopy. Obstetrics and Gynecology 2000; 95: 704-709.  Back to cited text no. 2
    
3.Prystowsky JB, Jericho BG, Epstein HM. Spontaneous bilat­eral pneumothorax - complication of laparoscopic cholecystec­tomy. Surgery 1993; 114: 988-92.  Back to cited text no. 3
[PUBMED]    
4.Joris JL. Anaesthesia for laparoscopic surgery. In: Miller RD editor: Anesthesia. New York: Churchill Livingstone 2005. p. 2285-2306.  Back to cited text no. 4
    
5.Chui PT, Gin J, Chung SCS. Subcutaneous emphysema, pneu­momediastinum and pneumothorax complicating laparoscopic vagotomy. Anaesthesia 1993; 48: 978-81.  Back to cited text no. 5
    
6.Perko G, Fernandes A. Subcutaneous emphysema and pneu­mothorax during laparoscopy for ectopic pregnancy removal. Acta Anaesthesiol Scand 1997; 41:792-794.  Back to cited text no. 6
[PUBMED]    
7.Joris JL, Chiche J, Lamy ML. Pneumothorax during laparoscopic fundoplication: diagnosis and treatment with positive end expi­ratory pressure. Anesth Analg 1995; 81: 993-1000.  Back to cited text no. 7
    
8.Ferzli GS, Kiel T, Hurwitz JB, et al. Pneumothorax as a compli­cation of laproscopic inguinal hernia repair. Surg Endosc 1997; 11: 152-154.  Back to cited text no. 8
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