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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 2  |  Issue : 3  |  Page : 118-120

Capnothorax during laparoscopic fundoplication: Diagnosis and anesthetic management


Department of Anaesthesiology, Shrimati Kashibai Navale Medical College and General Hospital, Narhe, Pune, Maharashtra, India

Date of Web Publication21-May-2014

Correspondence Address:
Dr. Poonam S. Ghodki
A 201, Doctors Quarters, Shrimati Kashibai Navale Medical College and General Hospital, Narhe, Pune - 411 041, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4855.132954

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  Abstract 

Laparoscopic procedures are commonly performed and preferred over open laparotomies due to their unique advantages. Many laparotomies are now amenable to laparoscopic repair. One such surgery is laparoscopic fundoplication for hiatus hernia repair. The advent of this surgery has given rise to unique consequences which may turn out to be complications if not attended appropriately.

Keywords: Capnothorax, fundoplication, laparoscopy, pnemoperitoneum, pneumothorax


How to cite this article:
Ghodki PS, Thombre SK. Capnothorax during laparoscopic fundoplication: Diagnosis and anesthetic management. J Acad Med Sci 2012;2:118-20

How to cite this URL:
Ghodki PS, Thombre SK. Capnothorax during laparoscopic fundoplication: Diagnosis and anesthetic management. J Acad Med Sci [serial online] 2012 [cited 2019 Jul 22];2:118-20. Available from: http://www.e-jams.org/text.asp?2012/2/3/118/132954


  Introduction Top


Laparoscopy has evolved over the past few decades and it has now secured its place not only for diagnostic, but also therapeutic surgical procedures. Laparoscopic appendicectomy, cholecystectomy, hysterectomy have become a thing of past. Surgeries like laparoscopic fundoplication are now gaining popularity over the invasive open surgical procedure for hiatus hernia repair. Laparoscopy provides unique advantages such as decreased post-operative pain, decreased hospital stay, cosmesis and reduced morbidity. However, the site of this surgery viz the hiatus makes it susceptible to unique complications occurring as a result of CO 2 insufflation for pneumoperitoneum. Subcutaneous emphysema, pneumothorax and pneumomediastinum are known complications of CO 2 insufflation. [1],[2] Anesthesiologists should be aware of these complications because they are highly preventable and treatable if diagnosed early. Hence, vigilant monitoring is required throughout the procedure.

We report a case of left sided capnothorax during laparoscopic fundoplicaiton and the ways to handle it.


  Case Report Top


This was a case of a 26-year-old female patient, American Society of Anesthesia (ASA) Grade I was posted for laparoscopic fundoplication for sliding type of hiatus hernia. Before induction electrocardiogram (ECG), pulse oximetry, non-invasive blood pressure monitors were attached and baseline values noted. Induction was carried out with propofol, fentanyl, vecuronium in conventional doses followed by endotracheal intubation. Placement of endotracheal tube was confirmed by bilaterally equal breath sounds and etCO 2 reading. Ventilation was carried out with tidal volume 500 ml, respiratory rate 12/min on low flow anesthesia with N 2 O:O 2 (60:40 ratio) using Ohmeda ventilator. Intra operative monitoring included ECG, pulse, blood pressure (BP), etCO 2 and Paw (airway pressure). Neuromuscular blockade was maintained with vecuronium top ups.

Before pneumoperitoneum, parameters were P-80/min, BP-118/76 mmHg, etCO 2 -35 mmHg, sPO 2 -100% and Paw-18 cmH 2 O. Patient was given lithotomy position and pneumoperitoneum was created with CO 2 insufflation (pressure-14 mmHg).

With establishment of pneumoperitoneum, there was increase in BP to 130/90 mmHg and etCO 2 to 40 mmHg. To compensate this; minute ventilation was increased to 7 l/min (respiratory rate-14/min) to maintain etCO 2 at around 40 mmHg. When the surgeons reached the hiatus and started handling the crus of diaphragm, there was further increase in etCO 2 to 48 mmHg. Minute ventilation was further increased to 7.5 l/min. Despite this the etCO 2 could not be maintained and Paw also started gradually rising to reach a value of 26 cmH 2 O. BP and pulse rate were maintained, however saturation started falling to 96% and then 93-94% respectively. A diagnosis of pneumothorax was made and confirmed by decrease air entry on left side. Immediate X-ray was done intra operatively that further confirmed the diagnosis of pneumothorax. However instead of rushing for intercostal drainage, we asked the surgeons to release the pneumoperitoneum for a while. Within 6-7 min of release of pneumoperitoneum, all the deranged parameters returned to normal. Saturation gradually improved to 100%, etCO 2 returned to 36 mmHg and Paw normalized to 18 cmH 2 O. Air entry became bilaterally equal again. Pnemoperitoneum was re-established and laparoscopic fundoplication was completed in next 30 min. The procedure remained uneventful thereafter.

At the end of the procedure, residual neuromuscular blockade was antagonized and patient extubated. Air entry was equal bilaterally and repeat chest X-ray showed a normal picture. Post-operative stay of the patient was uneventful and he was discharged after 2 days.


  Discussion Top


Hiatus hernia results from weakening of the crus of diaphragm leading to sliding of stomach from abdominal into thoracic cavity. In fundoplication, these crus are tightened either through laparotomy or laparoscopy. Laparoscopic fundoplication is comparatively a new procedure in the field of laparoscopy. It not only requires a skilled laparoscopist but also a vigilant anesthesiologist to monitor anticipate and treat complications arising from this novel surgery. Capnothorax during laparoscopy is uncommon and can be seen in laparoscopic cholecystectomy or nephrectomy due to either direct damage to diaphragm or through patent pleuroperitoneal ducts. [2],[3] However in laparoscopic fundoplication, despite all precautionary measures by laparoscopists the CO 2 may sweep through the hiatus, which is the operative site and enter the thoracic cavity. [4] This leads to pneumothorax, which in this case is actually a capnothorax, i.e. instead of air it is carbon dioxide in thoracic cavity. [4],[5]

Pneumothorax in laparoscopy can occur due to rupture of emphysematous bulla (e.g. in chronic obstructive pulmonary disease patients) or barotrauma. Thoracocentesis becomes mandatory in these cases and the use of positive end-expiratory pressure (PEEP) is contraindicated. [6] The etCO 2 in such pneumothorax rather falls while in capnothorax there is a gradual rise in etCO 2 levels which helps in differential diagnosis. Apart from capnothorax, endobronchial intubation, which is not uncommon after pnemoperitoneum should also be kept in mind. This occurs due to cephalad displacement of diaphragm after creation of pneumoperitoneum. To differentiate, in endobronchial intubation there will be absent air entry on one side with increase Paw and a dramatic fall in saturation. In doubt, fiberoptic bronchoscopy can confirm the diagnosis. The other differential diagnosis is subcutaneous emphysema, which can be confirmed by clinical examination. [7],[8]

We have described a case of spontaneous capnothorax in ASA Grade I patient undergoing laparoscopic fundoplication. The first sign was increased etCO 2 despite adjustments in minute ventilation followed by increase in Paw and falling saturation. And only clinical examination of chest led to correct diagnosis which was confirmed by chest X-ray. Such capnothorax in laparoscopic fundoplication should be anticipated and thorough monitoring should be carried out. A rise in etCO 2 after pnemoperitoneum is inevitable which is easily managed by increasing the minute ventilation. Problems arise when it is accompanied by increase Paw and decreased saturation not compensated by increasing the minute ventilation. When signs suggesting capnothorax arise, it should be confirmed by chest auscultation and release of pneumoperitoneum should be advised. This is a conservative management as CO 2 is highly soluble in blood and gets easily absorbed from pleural cavity. N 2 O must be discontinued and 100% oxygen needs to be administered until saturation improves. Once this is achieved surgery can be re commenced. The role of PEEP in capnothorax is controversial. [9] Instantly reacting to capnothorax by inserting an intercostal drainage is inappropriate and should be avoided as it has its own complications. Correct management is possible only if timely diagnosis of capnothorax is made else it may lead to massive capnothorax presenting with not only ventilatory but also circulatory instability making thoracocentesis mandatory increasing the morbidity of patient.

Laparoscopic fundoplication provides several benefits over open hiatus hernia repair. [10] However vigilant monitoring on the part of anesthesiologist is required to avoid unnecessary interventions. Other precautions such as keeping CO 2 insufflation pressure below 15 mmHg and decreased operative time (200 min) should be considered to avoid complications. Clinical examination still holds priority in diagnosing capnothorax leading to uneventful recovery of patient serving the purpose of laparoscopy.

 
  References Top

1.Woolner DF, Johnson DM. Bilateral pneumothorax and surgical emphysema associated with laparoscopic cholecystectomy. Anaesth Intensive Care 1993;21:108-10.  Back to cited text no. 1
    
2.Murdock CM, Wolff AJ, Van Geem T. Risk factors for hypercarbia, subcutaneous emphysema, pneumothorax, and pneumomediastinum during laparoscopy. Obstet Gynecol 2000;95:704-9.  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
    
4.Hanning CD, Veitch PS. Pneumothorax and laparoscopic fundoplication. Anaesthesia 1995;50:1099-100.  Back to cited text no. 4
[PUBMED]    
5.Leong LM, Ali A. Carbon dioxide pneumothorax during laparoscopic fundoplication. Anaesthesia 2003;58:97.  Back to cited text no. 5
    
6.Sato Y, Miwa T, Hiroki K. Tension pneumothorax during laparoscopic Nissen fundoplication in a child. J Clin Anesth 2007;19:162-3.  Back to cited text no. 6
[PUBMED]    
7.Chui PT, Gin T, Chung SC. Subcutaneous emphysema, pneumomediastinum and pneumothorax complicating laparoscopic vagotomy. Report of two cases. Anaesthesia 1993;48:978-81.  Back to cited text no. 7
    
8.Perko G, Fernandes A. Subcutaneous emphysema and pneumothorax during laparoscopy for ectopic pregnancy removal. Acta Anaesthesiol Scand 1997;41:792-4.  Back to cited text no. 8
    
9.Joris JL, Chiche JD, 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. 9
    
10.Yamamura MS, Gilster JC, Myers BS, Deveney CW, Sheppard BC. Laparoscopic Heller myotomy and anterior fundoplication for achalasia results in a high degree of patient satisfaction. Arch Surg 2000;135:902-6.  Back to cited text no. 10
    




 

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