Derek Lim, DO, Shinban Liu, DO, Claudia Kim, DO, Michael Timoney, MD. NYU Langone Medical Center
Case Description: A 30-year-old female with no past medical or surgical history presents with a symptomatic right inguinal hernia for 1 month prior to evaluation. She underwent a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair. Three infraumbilical ports were used and the pre-peritoneal space was insufflated to 12mmHg. Appropriate structures were visualized and the hernia was repaired with mesh in the standard fashion after extensive dissection. She was discharged the same day with no complaints.
She returned to the emergency room that night complaining of sharp pleuritic chest pain which radiated to the back and neck. She denied any fevers, dysphagia, cough or shortness of breath. Physical exam was negative for chest wall or neck crepitus. CT chest demonstrated evidence of pneumomediastinum and pneumoperitoneum. She was admitted and observed overnight with improvement of symptoms the following morning. She was discharged after tolerating a diet and without requiring any further interventions.
Discussion: Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is a growing technique amongst minimally invasive surgeons. This approach allows for the repair of all three inguinal spaces (direct, indirect and femoral) as well as bilateral inguinal hernias with only three incisions. Pneumomediastinum is a rare complication after a TEP procedure, with a reported incidence of only 0.1-0.3%. Insufflated carbon dioxide can enter into the thoracic cavity through three fascial planes; subcutaneous fascia, retroperitoneum (myopectineal dissection) or transdiaphragmatic (congenital diaphragmatic hernia or aortic/esophageal hiatus). Each route may present differently ranging from chest wall crepitus to a pneumothorax. Risk factors include high working CO2 insufflation pressures (>10mmHg), extensive dissection, and prolonged duration of surgery. CO2 diffuses through tissue very rapidly and often patients can be observed for 24 hours and managed conservatively. There is no role for repeat imaging as long as the patient remains asymptomatic and stable.
Although uncommon, early recognition of pneumomediastinum is important to prevent further complications such as respiratory distress or cardiac compromise. Anesthesiology must be cognizant intraoperatively as a pneumothorax secondary to progressive pneumomediastinum may complicate airway management.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 92389
Program Number: P570
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster
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