Life-Threatening Tracheal Diverticulum Rupture Following Laparoscopic Cholecystectomy: A Rare Case Report

BACKGROUND We present an exceptional case of asystole and tracheal diverticulum rupture as a result of cardiopulmonary resuscitation (CPR) immediately following laparoscopic cholecystectomy performed at Riga 1st Hospital. Tracheal rupture after tracheal intubation is a severe but very rare complication that can be fatal. We present an incidental finding of the tracheal diverticulum and its rupture during CPR. CASE REPORT A 71-year-old woman (American Society of Anesthesiologists class II, body mass index 28.58) underwent a planned laparoscopic cholecystectomy. Preoperative chest X-ray showed no abnormalities. Endotracheal intubation was performed, with the first attempt with a 7-mm inner diameter cuffed endotracheal tube without an introducer. Five minutes after rapid desufflation of the pneumoperitoneum, severe bradycardia and hypotension occurred, followed by asystole. CPR was performed for a total of 2 min, until spontaneous circulation returned. Twenty hours after surgery, subcutaneous emphysema appeared on the chest. Computed tomography scan of the chest revealed subcutaneous neck emphysema, bilateral pneumothorax, extensive pneumomediastinitis, and a pocket-like, air-filled tissue defect measuring 10×32 mm in the distal third of the trachea, with suspected rupture. Two hours after the diagnosis was established, the emergent surgery was performed. The patient was completely recovered after 15 days. CONCLUSIONS Our case illustrates that tracheal diverticula is sometimes diagnosed by accident and too late, which then can lead to life-threatening situations. Tracheal rupture can be made not only by mechanical piercing by an endotracheal tube but also during interventions, such as CPR. Rapid desufflation of the pneumoperitoneum can lead to asystole, induced by the Bezold-Jarisch reflex.