Postoperative pneumoperitoneum after colorectal surgery: Expectant vs surgical management

Postoperative pneumoperitoneum poses a clinical dilemma. Depending on the cause, its management includes a spectrum from simple observation and supportive care to surgical exploration. The aim of this paper is to present four clinical cases and propose an algorithm for the management of postoperative pneumoperitoneum based on available literature. The causes, diagnosis and possible complications arising from pneumoperitoneum will also be discussed. Three of the four cases presented were successfully managed conservatively and one had an exploratory laparotomy with negative findings. In such scenarios, it is important to consider the nonsurgical causes of pneumoperitoneum, which include pseudopneumoperitoneum, thoracic, abdominal, gynecological and idiopathic. These causes do not always require emergent exploratory laparotomy. The surgical team needs to consider the history, physical exam and diagnostic workup of the patient. If a patient presents with peritoneal signs, then exploratory laparotomy is a must. Since 10% of the cases of pneumoperitoneum are caused by nonsurgical entities, managed expectantly, a negative exploratory laparotomy and its associated risks are avoided.