Acute ventilatory complications during laparoscopic upper abdominal surgery

This article examines and summarizes the published reports dealing with subcutaneous emphysema, pneumothorax and carbon dioxide (CO2) embolism during laparoscopic upper abdominal surgery. The purpose is to describe the expected clinical picture, the differential diagnosis and the management of these complications.

The information was obtained from a Medline literature search and the annual meeting supplements of Anesthesiology, Anesth Analg, Br J Anaesth and Can J Anaesth.

An abrupt increase in PETCO2 is the first sign of subcutaneous emphysema and of pneumothorax. Desaturation and increased airway pressure occur with pneumothorax, but not with subcutaneous emphysema alone. Desaturation and increased airway pressure also occur with bronchial intubation. The preliminary diagnosis is made by verifying the position of the tube, examination of the patient for swelling and crepitus and auscultation for air entry. Chest radiography and paracentesis confirm the diagnosis of pneumothorax, which frequently occurs with subcutaneous emphysema but is rarely of the tension type. Pulmonary embolism due to CO2 during LUAS has not been reported, but the available data suggest that small, haemodynamically inconsequential CO2 embolism occurs without change in PETCO2. Massive embolism is possible and will markedly decrease PETCO2, arterial O2 saturation (SpO2) and blood pressure.

The immediate recognition of the three complications requires continuous monitoring of PETCO2, arterial saturation, airway pressure, and an index of pulmonary compliance.