Pneumothorax As a Delayed Complication of Laparoscopic Extraperitoneal Bilateral Inguinal Hernia Repair

Sean Satey, MD, Emilio Alonso, MD, Afshin Molkara, MD, FACS, Yong-Kwon Lee, MD, FACS. University of California, Riverside

Objective: Totally transabdominal extraperitoneal (TEP) repair and transabdominal preperitoneal (TAPP) repair are two techniques used for laparoscopic inguinal hernia repair (LIHR). LIHR has been associated with decreased length of stay, return to normal activity, and postoperative complications when compared to its open counterpart. Complications of LIHR are well documented; however, the development of pneumothorax, pneumomediastinum and subcutaneous emphysema are rarely reported. These potentially lethal complications must be diagnosed and managed immediately. The objective of this paper is to present an unexpected case of pneumothorax after a bilateral LIHR with a review of the literature.

Methods: A 56-year-old man, ASA 2, with bilateral inguinal hernia was admitted for elective inguinal hernia repair using the TEP approach. After an uneventful intubation, the standard TEP repair was performed using three midline trocars. Upon emergence from anesthesia, the patient became tachypneic and tachycardic, requiring esmolol for heart rate control. His oxygen saturation declined to the mid 80s and he was noted to have poor respiratory effort despite being fully reversed. Respirations were assisted until tidal volumes improved. Upon extubation, the patient immediately reported severe chest pain on inspiration. He was placed on supplemental oxygen at 10L/min to maintain oxygen saturation in the mid 90s. Stat EKG, CXR, ABG and cardiac enzymes were obtained in the PACU. ABG demonstrated pH 7.306, PCO2 44.2, PaO2 76.5 and HCO3 21.6. EKG indicated minimal ST elevations in V1-V3. Serial CKMB was within normal limits. Serial Troponin I was 0.017, 0.641, and 0.442. Cardiology was consulted and conservative medical management was recommended. Chest x-ray indicated a 15% right-sided apical pneumothorax. High flow oxygen was continued and weaned as tolerated by time of discharge. Serial chest x-rays indicated resolution of the pneumothorax by post-operative day (POD) two. The patient was discharged on POD 4 with uneventful surgery and cardiology follow up visits.

Conclusion: While the development of pneumothorax, pneumomediastinum and subcutaneous emphysema are rarely reported, their occurrence may result in potentially lethal situations that require emergent diagnosis and management. Review of the limited literature suggests that the procedure duration and pre-peritoneal insufflation pressure positively correlate to the development of these complications. TEP and TAPP approaches to LIHR are generally safe. However, a low threshold of suspicion should be used in patients who present with intra-operative hemodynamic instability and/or post-operative tachypnea, tachycardia and chest pain. Pneumothorax, pneumomediastinum and subcutaneous emphysema are rare but serious complications of LIHR.

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