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Pneumothorax as a rare complication during laparoscopic total extra-peritoneal inguinal hernia repair: A case report and review of the literature
Nikolaos Koliakos1, Dimitrios Papaconstantinou1, Andrianos-Serafeim Tzortzis1, Dimitrios Schizas2, Dimitrios Bistarakis1, Anargyros Bakopoulos1
1 3rd Department of Surgery, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
2 1st Department of Surgery, Medical School, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
|Date of Submission||24-Jan-2021|
|Date of Decision||28-Feb-2021|
|Date of Acceptance||15-Mar-2021|
|Date of Web Publication||01-May-2021|
3rd Department of Surgery, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini Street 1, 12462, Athens
Source of Support: None, Conflict of Interest: None
Totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal repair are the two most commonly performed types of laparoscopic hernia repair procedures. Herein, we present a rare case of pneumothorax and pneumomediastinum that ensued during a TEP inguinal hernia repair. A 73-year-old man presented for elective laparoscopic right-sided hernia repair. After intubation, a 10-mm and two 5-mm trocars were placed in the peri-umbilical and midline area, respectively. A balloon dissector was inserted from the 10-mm trocar to develop the retro-rectus space and carbon dioxide was insufflated up to a pressure of 14 mmHg. About 55 min after insufflation, the patient presented subcutaneous emphysema, oxygen saturation dropped from 100% to 96% and pCO2 increased to 55 mmHg. Due to concerns for pulmonary embolism, he immediately underwent a chest computed tomography, which revealed pneumothorax, pneumomediastinum and subcutaneous emphysema extended throughout the neck, thorax and upper abdomen. The patient was successfully treated conservatively with oral analgesia and supplemental oxygen and was discharged on the 4th post-operative day without any further complications.
Keywords: Inguinal hernia repair, pneumothorax, totally extra-peritoneal
|How to cite this URL:|
Koliakos N, Papaconstantinou D, Tzortzis AS, Schizas D, Bistarakis D, Bakopoulos A. Pneumothorax as a rare complication during laparoscopic total extra-peritoneal inguinal hernia repair: A case report and review of the literature. J Min Access Surg [Epub ahead of print] [cited 2021 Jun 14]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=315378
| ¤ Introduction|| |
Totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) repairs are the two most commonly performed types of laparoscopic hernia repair procedures and are considered a good substitute to open surgery. According to the Swedish Hernia Registry, only 11% of the total inguinal hernia repair procedures were performed laparoscopically in 1999, while during the last decade, the relevant rates have reportedly exceeded 20%. In turn, the increasing application of laparo-endoscopic hernia procedures has resulted in a subset of rare post-operative complications relative to the use of gas insufflation during TEP and TAPP repairs. Herein, we present a rare complication of pneumothorax and pneumomediastinum that was encountered during a TEP inguinal hernia repair.
| ¤ Case Report|| |
A 73-year-old man, with American Society of Anesthesiologists physical status of 2, presented for elective laparoscopic right groin hernia repair. His medical history was notable for hypertension, nephrolithiasis and hyperuricaemia. An elective TEP approach was decided.
Tracheal intubation was easily performed. A 10-mm and two 5-mm trocars were placed in the peri-umbilical and midline area, respectively. A balloon dissector was inserted from the 10-mm trocar to develop the retro-rectus space and carbon dioxide was insufflated with a flow rate of 6 L/min up to a pressure of 14 mmHg. Dissection revealed a right indirect defect. Throughout the procedure, the patient was hemodynamically stable without any decrease in SpO2, while partial pressure of end-tidal carbon dioxide was maintained below 40 mmHg. The peak inspiratory airway pressure was 25–28 mmHg. Approximately 55 min after insufflation, the patient developed subcutaneous emphysema, oxygen saturation dropped from 100% to 96% and pCO2 increased to 55 mmHg. Expedited mesh placement was completed within the next 15 min, while the anaesthesia team reduced the administered tidal volume and increased the respiratory rate and positive end-expiratory pressure. The patient was subsequently extubated after normalisation of respiratory parameters. In the post-anaesthesia care unit, the patient showed signs of respiratory distress and complained of right-sided pleuritic chest pain, while maintaining oxygen saturation above 96%. Due to concerns for pulmonary embolism, he immediately underwent a chest computed tomography (CT), which revealed pneumothorax, pneumomediastinum and subcutaneous emphysema extending throughout the neck, thorax and upper abdominal wall, with no evidence of pneumoperitoneum [Figure 1].
|Figure 1: Computed tomography scan demonstrating bilateral pneumothorax and subcutaneous thoracic emphysema|
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The patient was treated conservatively with oral analgesia and supplemental oxygen. A chest CT on the 3rd post-operative day showed complete resolution of the pneumothorax. He was discharged on the 4th post-operative day without any further complications.
| ¤ Discussion|| |
Complications following laparoscopic hernia repair are related to the establishment of accidental pneumoperitoneum, the insertion of trocars and mesh fixation.
Pneumothorax is a rare complication that may result in life-threatening complications when undetected, and thus, a high index of suspicion is needed to ensure a timely diagnosis and treatment. In particular, gas may enter the thoracic cavity via different routes. These include the hiatuses of the diaphragm (aortic, oesophageal), retroperitoneal space, the Bochdalek foramen and through congenital deformities of the diaphragm. In addition, gas from the extra-peritoneal space can enter the thoracic cavity between the sternal and costal portion of the diaphragm and the rib cage, which arguably represents the most common mechanism that results in pneumothorax during TEP hernia repair. Reported risk factors linked to this complication are increased patient age and associated skin frailty, low body mass index and the coexistence of metabolic disease.
In reviewing the existing literature, only 15 cases of pneumothorax during laparoscopic inguinal hernia repair have been reported, to date. These have mainly occurred among male patients who underwent TEP repairs.,,,,,,,,,,,,, The current case is one of the few cases of pneumothorax following laparoscopic inguinal hernia repair in the literature [Table 1]. A number of alarm signs, including intra-operative hypoxaemia, hypercapnia and subcutaneous emphysema should raise the suspicion of pneumothorax which may necessitate chest imaging. The presence of pneumopericardium or pneumomediastinum is best visualised with chest CT.,,, In case of tension pneumothorax, chest tube decompression should be immediately performed without chest X-ray confirmation. Prolonged intubation is needed in cases with extreme respiratory derangements.,, Finally, conversion to open inguinal hernia repair is rarely needed, although expeditious completion of the laparoscopic procedure in low insufflation pressures is always mandated in such cases.,
|Table 1: Synopsis of existing cases of pneumothorax/pneumomediastinum following laparoscopic hernia repair|
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In conclusion, signs of respiratory distress during extra-peritoneal laparo-endoscopic hernia repair should strongly raise the suspicion for pneumothorax, provided that inadvertent entry into the peritoneal space has been ruled out. Intra-operative minimisation of CO2 insufflation pressure may help mitigate the risk for developing this complication. Conservative treatment is successful in most cases; however, therapy must be individualised based on severity of clinical symptoms and existing comorbidities.
Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient/parent/guardian/relative of the patient. A copy of the consent form is available for review by the Editor of this Journal.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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