Case Report

Pneumopericardium and Severe SubcutaneousEmphysema after Laparoscopic Surgery

Ma-Lee Ko, MD, MHA*From the Department of Obstetrics and Gynecology, Cheng-Hsin General Hospital, Taipei, Taiwan.

ABSTRACT Subcutaneous emphysema is a known complication of laparoscopic surgery. Occasionally, subcutaneous emphysema is severe

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and Gynecology,

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enough to cause pneumopericardium. This case report describes a rare but potentially serious complication of pneumopericar-

dium occurring after laparoscopy. Contributing factors and possible etiologies are discussed. Journal of Minimally Invasive

Gynecology (2010) 17, 531–533 � 2010 AAGL. All rights reserved.

Keywords: Pneumopericardium; Subcutaneous emphysema

Laparoscopic surgery is being performed with increasing

frequency in gynecology because of its advantages including

shorter hospital stay, less operative wound pain, and faster

recovery. Laparoscopic surgery in gynecology, however, is

not free of complications. Subcutaneous emphysema is one

of the most common but perhaps most underreported compli-

cation of this procedure. According to McAllister et al [1],

subcutaneous emphysema occurs in 20% to 60% of all lapa-

roscopic operations. When subcutaneous emphysema was

evaluated on postoperative x-ray films, Wolf et al [2] found

the incidence to be 34% to 77%. Occasionally, carbon

dioxide (CO2) accidentally enters the mediastinum and

even the pericardium. Although most often this resolves in-

stantaneously, at times it may be severe enough to be life-

threatening. Herein, we report a case of severe subcutaneous

emphysema with pneumopericardium that was observed

during laparoscopic adnexectomy of a borderline tumor.

Case Report

A 29 year old G0 P0 woman with a body mass index of 20

was admitted to the emergency room with severe and sudden

onset of lower abdominal pain. The patient denied sexual

intercourse within the last 48 hours. However, she reported

dyspareunia and painful menstruation for the last 3 years.

commercial, proprietary, or financial interest in the prod-

s described in this article.

thor: Ma-Lee Ko, MD, MHA, Department of Obstetrics

Cheng-Hsin General Hospital, Taipei 112, Taiwan.

n@yahoo.com

ber 18, 2009. Accepted for publication March 7, 2010.

.sciencedirect.com and www.jmig.org

front matter � 2010 AAGL. All rights reserved.

g.2010.03.006

In the emergency room, her vital signs were stable. Physical

examination revealed direct and rebound tenderness of the

right lower abdomen. Blood tests demonstrated leukocystosis

(19 000/mL3) with 97% neutrophils. The patient was referred

for gynecologic consultation, and a pelvic examination

elicited cervical motion tenderness. The right adnexa was

enlarged and tender. Ultrasound examination of the pelvis

demonstrated a cystic right adnexa measuring 8 ! 6 cm.

There was also fluid in the cul-de-sac, which was estimated

at 400 mL. The patient was scheduled for emergency laparo-

scopic surgery because of a ruptured right ovarian cyst.

General anesthesia was administered with endotracheal

intubation, and the patient was placed in the dorsolithotomy

position. A uterine manipulator was fixed on the cervix via

a tenaculum to enable uterine mobilization. A Veress needle

was first placed in the umbilicus, and insufflation was started

at 1 L/min, with an initial pressure of less than 8 mm Hg.

Hyperdistention of the abdominal cavity to an insufflation

pressure of 25 mm Hg was achieved before inserting the

ports: one 10-mm trocar for visualization and three 5-mm tro-

cars for instruments (1 placed in the suprapubic area and 2

ports placed laterally on each side of the abdomen). After

the ports were inserted, insufflation pressure was reduced

to 15 mm Hg, which was maintained during the operative

procedure. Ventilation parameters during insufflation in-

cluded oxygen saturation as measured using pulse oximetry

(SpO2), 99 mm Hg; extrapolated end-tidal CO2 tension

(PETCO2), 35 mm Hg; and airway pressure, 21 cm of water.

A large right ovarian mass occupying the entire pelvis was

observed, and approximately 350 mL of mucinous fluid was

aspirated from the cyst. Minute papillary excrescences were

also noted to protrude from the cyst capsule. A frozen section

Fig 1. Chest radiograph reveals subdiaphragmatic air and a clearly identifi-

able pneumopericardium.

532 Journal of Minimally Invasive Gynecology, Vol 17, No 4, July/August 2010

of the ovarian tissue fragment demonstrated a mucinous bor-

derline tumor, with mild to moderate nuclear atypia. There

was no evidence of destructive stromal invasion. Unilateral

adnexectomy was performed, followed by appendectomy.

Midway through the appendectomy (85 minutes into the

surgery), an increase in PETCO2 (60 mm Hg) and acidosis

(arterial blood gas pH, 7.13; PCO2, 80 mm Hg; PO2, 521

mm Hg; base excess, 23.8) were observed. A central line

was not placed.

Meticulous examination of the upper part of the body un-

der the surgical drapes revealed subcutaneous emphysema

over the thorax, neck, and face. Crepitus was also palpated

over the same areas. Hypercarbia was corrected by increasing

fraction of inspired oxygen to 1 (100% O2). The insufflation

pressure was also lowered and maintained at 12 mm Hg, and

the surgery was then completed. The operation lasted for 180

minutes, and pneumoperitoneum for 120 minutes. Blood loss

was minimal (100 mL). Assisted ventilation was adminis-

tered for another 15 minutes after surgery. The patient’s vital

signs remained stable. Extubation requirements were met,

and no hypercarbia was demonstrated. The patient was

observed in the postanesthesia care unit. Half an hour postop-

eratively, the patient suddenly developed sharp localized sub-

sternal chest pain. The pain was aggravated by breathing and

was associated with cold sweating, pallor, and difficulty in

breathing. Heart sounds were distant at auscultation. An elec-

trocardiogram showed diffuse T-wave abnormalities, with

T-wave inversion in leads V2 to V6. Because of concern for

evolving myocardial ischemia, the patient was transferred

to the intensive care unit. The serum creatine kinase-MB con-

centration was within normal limits. Troponin T and D-dimer

were both negative. A chest radiograph revealed subdiaph-

ragmatic air and a clearly identifiable pneumopericardium

(Fig 1). The pneumopericardium was managed expectantly,

and the chest pain with naproxen sodium (Naprosyn; Kojar

Pharmaceutical Industrial Co Ltd., Taiwan), 500 mg 3 times

a day. The symptoms decreased, and finally resolved by

postoperative day 3, at which time an electrocardiogram

demonstrated resolution of the T-wave abnormalities.

Follow-up chest x-ray films showed progressive reduction

of the pneumopericardium. Five days later, the patient was

discharged from the hospital without symptoms.

Discussion

Subcutaneous emphysema is a known complication of

laparoscopic surgery, and is caused by extravasation of

CO2 into the subcutaneous tissues. It has been perceived as

a relatively harmless complication [3]. However, severe sub-

cutaneous emphysema could lead to severe hypercarbia. This

is brought about by gaseous interchange between the subcu-

taneous CO2 and blood perfusing into the subcutaneous

tissue [3–5]. Occasionally, subcutaneous CO2 may dissect

into the prefascial planes, leading to pneumothorax,

pneumomediastinum, and pneumopericardium [5]. Although

pneumopericardium has been recognized after laparoscopic

urologic and gastrointestinal procedures, it has rarely been

reported after a gynecologic laparoscopy procedure. Most

cases were asymptomatic and were diagnosed incidentally

at radiography. Some patients reported abdominal pain as

the initial symptom, which led to the diagnosis [6].In some

cases, pneumopericardium mimics acute myocardial

ischemia, severe enough to cause electrocardiograph

abnormalities, as in our patient [7,8].

Several factors are associated with development of severe

subcutaneous emphysema at laparoscopy. According to Mur-

dock et al [9] and Esposito et al [10], development of emphy-

sema increases with age because the natural subcutaneous

resistance to gas insufflation decreases with age. A body

mass index less than 25 was also significantly associated

with development of subcutaneous emphysema [11]. Dura-

tion of the operative procedure, higher insufflation pressure,

use of more than 3 surgical ports, and the extraperitoneal

laparoscopic approach are among the operative factors

identified [3,12]. Creation of a false passage during trocar

placement, manipulation of instruments at acute angles, and

faulty trocar seals at entry and exit points are among other

causes [12,13].

The etiology of pneumopericardium as a result of laparo-

scopic procedure is unclear. According to Nicholson and

Berman [14], gas can reach the pericardial cavity and the

mediastinum via a path along the inferior vena cava through

the diaphragm. Thus, with increased insufflating pressure,

CO2 could track through an existing congenital defect of

the pericardial sac.

Pneumothorax has been reported during laparoscopic

procedures. During surgery, an increase in positive

Ko. Pneumopericardium 533

inspiratory pressure, a decrease in SpO2, and decreased breath

sounds on 1 side suggest the diagnosis, which should be con-

firmed at chest radiography [15]. The laparoscopist may be

able to demonstrate abnormal motion of 1 hemidiaphragm.

Reduced QRS amplitude in precordial electrocardiographic

leads further supports the diagnosis. The surgeon and the

anesthesiologist should be aware of decreasing mean arterial

pressure and SpO2, which suggests tension pneumothorax,

because immediate decompression is required.

Increased CO2 load observed during extraperitoneal insuf-

flation can usually be corrected with controlled ventilation,

and may be averted by increasing minute ventilation. Chest

tube drainage should not be performed during surgery

because it will make it difficult to maintain the pneumoperi-

toneum. Increasing the fraction of inspired oxygen to 100%,

addition of 5 cm of positive end-expiratory pressure, and

reduction of intra-abdominal pressure to less than 15 mm

Hg will maintain oxygenation and enable surgery to be

completed [16,17].

Subcutaneous emphysema at physical examination and

radiographic pneumodissection typically resolve over several

hours or sometimes after 3 to 4 days [17]. Both conditions are

usually self-limiting and are managed expectantly. Explana-

tion and reassurance may be necessary for the patient in the

postoperative care unit.

In conclusion, surgeons should be aware of the possibility

of pneumopericardium in patients with chest pain and electro-

cardiographic abnormalities after a laparoscopic procedure.

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