[Laparoscopic cholecystectomy in a patient with honeycomb lung]

Laparoscopic surgery of the gallbladder has increasingly replaced open techniques due to postoperative benefits (less pulmonary complications, less postoperative pain, earlier mobilisation). Specific intraoperative effects of pneumoperitoneum have led to some uncertainty if cardiac and/or pulmonary high-risk cases should be done laparoscopically. We describe anaesthesiological management of a 72 year old patient with a unilateral leftsided honeycomb lung (two very large cysts) to undergo laparoscopic cholecystectomy. Vital capacity was reduced to 45%, forced expiratory 1 second volume to 41%, preoperative bloodgas analysis revealed a paO2 of 64 mmHg and a paCO2 of 40 mmHg. Under spontaneous breathing the patient was fiberoptically intubated with a left sided double lumen tube (Mallinckrodt, Athlone/Irland; 37 Ch) using balanced anaesthesia. The healthy right lung was hand ventilated with 100% oxygen to avoid excessive airway pressures (peak airway pressure 27 mbar, mean airway pressure 22-24 mbar). The diseased left lung was passively insufflated with oxygen. The intraabdominal pressure was limited to 10 mmHg. Muscle relaxation was achieved with atracurium under monitoring using a nerve stimulator. The paCO2 increased from 40 to 57 mmHg during the operation, but returned to normal immediately postoperatively. All other ventilatory and hemodynamic parameters were uneventful during the 35 minute procedure. The patient was extubated at the end of the procedure and monitored on the intensive care ward for one night. A postoperative chest X-ray revealed a mediastinal shift of 2 cm to the right, healthy side as well as an atelectasis on this side. The shift was most likely due to hypoventilation of the right lung, with the ensuing atelectasis drawing the mediastinum to the right. Under physiotherapy this shift had resolved by the next morning. The patient could be discharged from hospital on day seven and fully recovered. Especially the severely cardiopulmonary compromised patient benefits from a laparoscopic procedure, due to less postoperative reduction of pulmonary function. Careful and individually adapted monitoring and anaesthetic techniques are necessary to successfully counteract the special implications of pnemoperitoneum.