Tension pneumothorax caused by the argon beam coagulator during laparoscopic partial nephrectomy.

Pneumothorax is a well known complication of laparoscopic abdominal surgery. We report a case of tension pneumothorax caused by use of an argon beam coagulator in the retroperitoneal space during laparoscopic partial nephrectomy. CASE REPORT A 5-year-old female weighing 18.2 kg. had previously undergone bilateral ureteral implantation for vesicoureteral reflux with duplication of the left ureter. Subsequently obstruction of the ureter to the upper pole of the left kidney developed. Endoscopic dilation of the obstruction was unsuccessful and, thus, it was elected to perform laparoscopic partial nephrectomy of the upper pole of the left kidney for an atrophic segment. The patient was placed under general anesthesia with propofol and desflurane. Muscle relaxation was achieved with intermittent boluses of rocuronium. After intubation the child was placed in the right lateral decubitus position. Anesthesia was maintained with desflurane and meperidine. No nitrous oxide was used. The procedure was performed via a 10 mm. subcostal laparoscopic portal and 2 lower 5 mm. portals. The retroperitoneal space was hydrostatically dilated and carbon dioxide was introduced via the Hassan trocar. Carbon dioxide was insufflated at 3 l. per minute to a pressure of 12 cm. H 20. The argon beam coagulator was set on automatic, which delivers 3 to 12 l. gas flow per minute. The entire kidney was dissected free using sharp and blunt dissection. The branch renal artery and vein were then dissected on the posterior aspect of the kidney behind a large dilated upper pole ureter, and then clipped and transected. The ureter was transected and hemostasis was achieved. A harmonic scalpel was then used to amputate the upper third of the kidney. At various times diathermy or the argon beam coagulator were used to facilitate hemostasis. When the argon beam coagulator was used the trocars were opened to allow egress of argon gas to avoid increasing the retroperitoneal space pressure. The atrophic segment of kidney was removed uneventfully. There was no difficulty during any stage of the operation and no other organs were injured during the procedure. After removal of the upper renal pole oxidized regenerated cellulose was welded to the upper pole stump using the argon beam coagulator. Oxygen saturation immediately decreased from 100% to 80% and ventilator pressure increased to 35 cm. water. Both sides of the chest were auscultated and equal breath sounds were heard. Blood pressure then decreased from 100/55 to 75/40 mm. Hg, and the high pressure alarm on the carbon dioxide insufflator immediately sounded. As pneumothorax was suspected, the procedure was swiftly terminated and the patient was turned supine. Chest x-ray confirmed pneumothorax (see figure). A thoracostomy tube was rapidly placed. There was a gush of gas, and immediate resolution of the hypotension and hypoxemia followed. The surgery was completed uneventfully and the patient was extubated at the end of the procedure. The chest tube was removed the next day. Except for subcutaneous emphysema over the chest and face, the patient manifested no sequelae of this event. She was discharged home on postoperative day 3 and continues to do well. DISCUSSION