Massive subcutaneous emphysema following laparoscopic nephroureterectomy: An unusual presentation

Sir, Laparoscopic approach to surgery has expanded its horizon tremendously. It is a preferred approach in many general, urological and thoracic procedures. Massive subcutaneous emphysema is a rare complication of laparoscopic surgery. We report here such a complication after laparoscopic nephroureterectomy using carbon dioxide (CO2) as an insufflating gas. A 62 yr old male, weight 65kg, American Society of Anesthesiologists physical status II was scheduled for nephroureterectomy for sarcoma left kidney through transperitoneal approach. The only positive history revealed in preoperative evaluation was hypertension since 2 yrs. In the operating room, intravascular cannulation was established after baseline routine monitoring [electrocardiography, non-invasive blood pressure, pulse oximetric oxygen saturation (SpO2) and end-tidal CO2, (ETCO2)]. Standard general anaesthesia induction and intubation was performed using injection fentanyl, propofol and vecuronium bromide. Patient was maintained on O2:N2O (35:65) and isoflurane. Pneumoperitoneum was created using CO2 insufflation and was maintained for 4 hours. Intraoperatively, cardiovascular parameters, EtCO2 and peak inspiratory pressure remained normal throughout. The intra- abdominal pressure was in the range of 12-13 mm Hg. Maximum EtCO2 noticed during this period was 42mm Hg, which was normalised by increasing minute ventilation. 3 h after creation of pneumo-peritoneum, patient was noted to have developed marked subcutaneous emphysema over face, neck and chest. Skin crepitus was more on lateral aspects of neck bilaterally. It involved both the eyelids. Caudal extent of emphysema could not be demarcated due to patient positioning and surgical drapes. Arterial blood gas analysis (ABG) was obtained and found to be normal. All ventilatory parameters including EtCO2 were within normal limits at this moment. The surgeon was notified about emphysema. Pneumoperitoneum was deflated after nephrectomy. Uretrectomy was done after opening the abdomen. Entire surgery lasted for 6 hrs. Facial swelling and crepitus over neck started resolving gradually after deflation of pneumoperitoneum. At the end of surgery, direct laryngoscopy was done to exclude the presence of pharyngeal emphysema and laryngeal oedema which may accompany subcutaneous emphysema of face and neck and can cause airway obstruction. Arterial blood gas (ABG) values were repeated and found to be normal. The patient was extubated after confirming audible leak on positive pressure ventilation, after deflating the endotracheal tube cuff, ruling out tracheal compression by neck emphysema. Gaseous collection was allowed to be drained by spontaneous absorption and exhalation. Patient was transferred to ICU for further monitoring. Postoperative chest radiograph in intensive care unit (ICU) confirmed the diagnosis of surgical emphysema in the neck and chest and ruled out pneumothorax and pneumomediastinum. Patient remained stable in post operative period and was transferred to ward next day. Massive subcutaneous emphysema is an extremely rare complication. [1,2] On palpation, it produces an unusual crackling sensation as the gas in pushed through the tissues. Severity of emphysema can be compared on a four point scale. [3] (0) No subcutaneous emphysema, (1) Mild emphysema with crepitus at trocar insertion site, (2) Mild emphysema with crepitus extending to the abdomen and thighs. (3) Massive emphysema extending to the chest, neck and face. Prolonged surgery and pneumoperitoneum of >200 minutes, insufflation of CO2 at pressure ≥15 mm Hg, 6 or more ports and old age due to decrease in natural subcutaneous resistance are the factors which predispose to the risk of development of subcutaneous emphysema. [4,5] The patient had massive subcutaneous emphysema probably due to prolonged pneumoperitoneum of 4 hours duration. Age of the patient was another possible factor which may be responsible for such massive emphysema. Absence of rise in EtCO2 was unusual, a finding contrary to most reports where an increase in EtCO2 was found along with massive subcutaneous emphysema. Our findings are consistent with the finding of Giorgakis and Fernandez-Diaz where they found no increase in EtCO2 intraoperatively. [6] In view of the paucity of literature showing massive subcutaneous emphysema in the absence of increased EtCO2, we wished to share our experience. We recommend that the patient should be closely examined under the drapes intraoperatively even if ventilatory parameters are normal on monitor.