Pleural effusion following use of saline and fluid anti‐adhesion agents at laparoscopic surgery—a case series of three patients

Laparoscopy is widely used for diagnostic as well as therapeutic purposes in gynaecology. The green top guidelines on the management of endometriosis produced by the Royal College of Obstetricians and Gynaecologists recommend advanced laparoscopic surgery for treatment of severe endometriosis. Here, we present three very unusual cases of hydrothorax developed as a complication of advanced laparoscopic surgery for endometriosis. The first patient was a 38-year-old nulliparous woman with BMI of 25.7 with known severe endometriosis referred to gynaecology clinic for consideration of advanced laparoscopic surgery. The patient had undergone diagnostic laparoscopy with no complications in the past. She was fit with no significant past medical history. Preoperative investigations were unremarkable. The patient was intubated, paralysed and ventilated during the operation. She was in lithotomy position with modest Trendlenburg tilt. An average intraperitoneal pressure of 15 mmHg was maintained during the procedure. Introperatively, she was found to have stage IV endometriosis with dense adhesions involving both tubes and ovaries. Laparoscopic adhesiolysis and laser treatment of endometriosis was carried out. The procedure lasted for 1 hour. A total of 3 l of normal saline were used for suction irrigation. Although the exact irrigation balance was not recorded, it was assumed that the majority of the fluid was recovered. At the end of the procedure, 1.5 l of ADEPT (4% icodextrin) was left in the peritoneal cavity. About 40–45 minutes into the operation, it became difficult to ventilate the patient. Her airway pressure increased, end tidal CO2 increased and oxygen saturation dropped from 100 to 90% on an FiO2 of 0.5. This occurred over a period of 5–10 minutes. Saturations improved to 96% on 100% oxygen. At this stage, almost 2500 ml of saline had been used for irrigation. On auscultation, breath sounds were present bilaterally. The operation was completed in the next 20 minutes. The patient required to be ventilated with 100% oxygen to maintain saturations over 90%. It was deemed unsafe to extubate the patient. Arterial blood gas analysis showed Po2 of 11.2 kPa and Pco2 of 7.8 kPa on 100% oxygen with 5 cm positive end-expiratory pressure (PEEP). At this stage, breath sounds were noticed to be diminished over the right side of the chest. A portable chest X-ray showed a white out of the right side (Figure 1). An ultrasound scan was performed, which demonstrated the presence of a large amount of fluid in the right hemithorax. A chest drain was inserted in the right pleural cavity and immediately, almost a litre of fluid was drained. Repeat arterial blood gas analysis showed Po2 of 43.2 kPa and Pco2 of 5.3 kPa. The right lung did not inflate adequately and thus the patient was transferred to ITU. She was ventilated overnight and extubated the following morning and recovered rapidly. The patient was discharged home on the subsequent day from the ITU. Cytology and microbiology examination of the fluid was negative. The patient was reviewed for follow-up visit in the gynaecology clinic 3 weeks postoperatively and was well. The second patient was a 38-year-old nulliparous woman with the BMI of 24 and known Stage IV endometriosis. She had undergone laparoscopy and laser treatment of endometriosis 3 years ago without any complications. Normal saline was used for irrigation and 1 l of ADEPT was left in the peritoneal cavity at the end of the procedure. She then had two cycles of IVF with unsuccessful outcomes and was referred from the assisted