[Hemilateral hydrothorax and atelectasis during laparoscopic Nissen fundoplication]

A 57-year-old woman, weighing 75 kg, with gastroesophageal sliding hernia, received laparoscopic Nissen fundoplication under general anesthesia. Although artificial ventilation was carried out uneventfully when the surgery started, sudden decreases in SpO2 and thoraco-pulmonary compliance were noted after insufflation of CO2. Breath sound was not audible on the left lung. We suspected that inadvertent pneumothorax was produced, but chest X-ray and transesophageal echocardiography at the end of surgery revealed the presence of left hemilateral hydrothorax with pulmonary atelectasis. She was ventilated artificially and given diuretics and albumin solution for 3-days before extubation. We speculated on two reasons for the event: a possibility of perforation of the diaphragm manipulated by surgeons, and that of transition of fluid used for irrigation just below the diaphragm. Pulmonary atelectasis could be induced with hemilateral lung ventilation because cephalad shifting of the diaphragm might follow the intraperitoneal insufflation. We conclude that laparoscopic surgery with insufflation of gas and irrigation with fluid requires careful attention if the laparoscopic surgery is sustained with insufflation and irrigation.