Intraoperative tension pneumothorax during laparoscopic cholecystectomy as a presentation of delayed traumatic...

Traumatic diaphragmatic hernia (TDH) may present months to years after blunt injury and can mimic biliary or pulmonary disease. Right-sided TDH is particularly prone to delayed recognition because partial hepatic herniation may be overlooked unless the diaphragm is specifically reviewed.

A 45-year-old woman with a remote motor-vehicle collision developed right-sided tension pneumothorax with hemodynamic collapse at the start of laparoscopic cholecystectomy at another hospital; a chest tube and cardiopulmonary resuscitation were required and the operation was aborted. Fourteen months later, she presented to our institution with recurrent right-upper-quadrant pain. A targeted re-review of serial prior CT images demonstrated a hepatic collar sign along the right hemidiaphragm, consistent with hepatic herniation through a traumatic diaphragmatic defect. Cholecystectomy was deferred and urgent thoracoscopic repair was performed the same day. The patient recovered uneventfully and remained asymptomatic at 7-year follow-up.

Unexplained tension pneumothorax during laparoscopy may be a sentinel event of delayed TDH. Targeted CT re-review with attention to diaphragm-specific signs may help avoid inappropriate abdominal surgery and enable timely definitive repair.