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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


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 Submission24-Jan-2021
Date of Decision28-Feb-2021
Date of Acceptance15-Mar-2021
Date of Web Publication01-May-2021

Correspondence Address:
Dimitrios Papaconstantinou,
3rd Department of Surgery, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini Street 1, 12462, Athens
Greece
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_34_21

  Abstract 

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 Top


Totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) repairs are the two most commonly performed types of laparoscopic hernia repair procedures[1] 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,[2] while during the last decade, the relevant rates have reportedly exceeded 20%.[3] 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 Top


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 Top


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.[4] 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.[5]

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.[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19] 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.[9],[11],[13],[16] In case of tension pneumothorax, chest tube decompression should be immediately performed without chest X-ray confirmation.[8] Prolonged intubation is needed in cases with extreme respiratory derangements.[7],[13],[14] 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.[8],[10]
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.

Informed consent

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

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Wei FX, Zhang YC, Han W, Zhang YL, Shao Y, Ni R. Transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) for laparoscopic hernia repair: A meta-analysis. Surg Laparosc Endosc Percutan Tech 2015;25:375-83.  Back to cited text no. 1
    
2.
Nilsson E, Haapaniemi S. The Swedish hernia register: An eight year experience. Hernia 2000;4:286-9.  Back to cited text no. 2
    
3.
Palser TR, Swift S, Williams RN, Bowrey DJ, Beckingham IJ. Variation in outcomes and use of laparoscopy in elective inguinal hernia repair. BJS Open 2019;3:466-75.  Back to cited text no. 3
    
4.
Kleinman PK, Brill PW, Whalen JP. Anterior pathway for transdiaphragmatic extension of pneumomediastinum. AJR Am J Roentgenol 1978;131:271-5.  Back to cited text no. 4
    
5.
Ott DE. Subcutaneous emphysema – Beyond the pneumoperitoneum. JSLS 2014;18:1-7.  Back to cited text no. 5
    
6.
Ferzli GS, Kiel T, Hurwitz JB, Davidson P, Piperno B, Fiorillo MA, et al. Pneumothorax as a complication of laparoscopic inguinal hernia repair. Surg Endosc 1997;11:152-3.  Back to cited text no. 6
    
7.
Toyoshima Y, Tsuchida H, Namiki A. Pneumothorax during endoscopic extraperitoneal herniorrhaphy. Anesthesiology 1998;89:1040.  Back to cited text no. 7
    
8.
Sharma N, Kundu AK. Pneumothorax complicating total extraperitoneal repair of inguinal hernia under combined spinal epidural anaesthesia. ANZ J Surg 2014;84:797.  Back to cited text no. 8
    
9.
Teng TY, Lau CC. Unusual cause of pneumomediastinum in a laparoscopic extraperitoneal inguinal hernia repair. J Surg Case Rep 2014;2014:rju106.  Back to cited text no. 9
    
10.
Charulatha R, Balasubramanian S, Yogeshwaran. Intraoperative pneumothorax complicating totally extraperitoneal inguinal hernia repair. J Evol Med Dent Sci 2015;4:10545-8.  Back to cited text no. 10
    
11.
Cole WC, Mayo JS, Yheulon CG. Pericarditis as a result of pneumomediastinum after uncomplicated laparoscopic totally extraperitoneal inguinal hernia repair. Am Surg 2017;83:e192-3.  Back to cited text no. 11
    
12.
Harkin CP, Sommerhaug EW, Mayer KL. An unexpected complication during laparoscopic herniorrhaphy. Anesth Analg 1999;89:1576-8.  Back to cited text no. 12
    
13.
Ramia JM, Pardo R, Cubo T, Padilla D, Hernández-Calvo J. Pneumomediastinum as a complication of extraperitoneal laparoscopic inguinal hernia repair. JSLS 1999;3:233-4.  Back to cited text no. 13
    
14.
Browne J, Murphy D, Shorten G. Pneumomediastinum, pneumothorax and subcutaneous emphysema complicating MIS herniorrhaphy. Can J Anaesth 2000;47:69-72.  Back to cited text no. 14
    
15.
Madan AK, Likes M, Raafat A. Pneumomediastinum as a complication of preperitoneal laparoscopic herniorrhaphy. JSLS 2003;7:73-5.  Back to cited text no. 15
    
16.
Bartelmaos T, Blanc R, De Claviere G, Benhamou D. Delayed pneumomediastinum and pneumothorax complicating laparoscopic extraperitoneal inguinal hernia repair. J Clin Anesth 2005;17:209-12.  Back to cited text no. 16
    
17.
Lo CH, Trotter D, Grossberg P. Unusual complications of laparoscopic totally extraperitoneal inguinal hernia repair. ANZ J Surg 2005;75:917-9.  Back to cited text no. 17
    
18.
Kim HY, Kim TY, Lee KC, Lee MJ, Kim SH, Bahn JM, et al. Pneumothorax during laparoscopic totally extraperitoneal inguinal hernia repair – A case report-. Korean J Anesthesiol 2010;58:490-4.  Back to cited text no. 18
    
19.
Sucandy I, Kolff JW. Pneumothorax after laparoscopic extraperitoneal inguinal hernia repair: A potential complication that every general surgeon should know. Am Surg 2012;78:64-5.  Back to cited text no. 19
    


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    Tables

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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04