Pneumothorax: Laparoscopic Intraoperative Management During Fundoplication Facilitates Management of Cardiopulmonary Instability and Surgical Exposure

Anesthetic management

The occurrence of pneumothorax in the elderly patient population with multiple comorbidities, in the head up position, may compromise cardiorespiratory function during anesthesia, causing sudden onset of hypotension, tachycardia, or bradycardia. ¹ Such an occurrence frequently required returning the operating table to level and aspiration of carbon dioxide (CO₂) from the pleural space until the patient's hemodynamic situation stabilized. Pressors, atropine, and other agents were often necessary in a population group with a potential for cerebral ischemia. Management with intravenous arterial monitoring was valuable, allowing instantaneous detection of deteriorating blood pressure and facilitating early corrective intervention, which often appeared suddenly.

Surgical management

Identification and preservation of the pleura can prevent damage (Fig. 1); when the pneumothorax occurs, it is frequently visible as a rent in the pleura. The experienced surgeon will often instantaneously recognize a pleural breach and communicate this to anesthetics prior to the development of obvious pneumothorax and physiological deterioration (Fig. 2). Otherwise pneumothorax may appear as convex movement of the diaphragm or bulging on ventilation of the mediastinal pleura, frequently obscuring vision, and making dissection of the vagal nerves and posterior esophageal structures more difficult. Flattening the table and aspirating CO₂ are time consuming and temporary in nature, which requires further surgery performed at lower pressures with less adequate visualization. Avoidance of this situation is greatly advantageous in ease of surgery, potential for complications, and duration of surgery.

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FIG. 1.

Pleura: in the midline behind the esophagus.

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FIG. 2.

Pneumothorax: circular breach in the pleura with lung in background.

In our experience, as this condition occurred more commonly during surgery of PEH, however, dissection within the mediastinum emphasizing identification and preservation of the pleura decreased the incidence of inadvertent pneumothorax. Pleura was closely applied to the esophagus and often crossed the midline posteriorly. It was necessarily closely applied to the hernia sac and reduction of the hernia sac could pull the pleura into the operative field. Dissection of fatty tissue on the mediastinal surface of the sac and sweeping it back toward the lung helped preserve pleura. Absolute hemostasis aided vision of the pleura, for which harmonic scalpel was found highly useful (Johnston & Johnston Medical, Cincinnati, OH).

Multiple techniques were utilized to occlude pleural breach including PDS Endoloop (Fig. 3) (Ethicon Endo Surgery, Cincinnati, OH), a piece of hernia sack (Fig. 4), clips, hemostatic mesh gauze (Fig. 5), or V-lock suture (Covidien, Dublin, Ireland) (Fig. 6) for larger defects (Figs. 1–5). Occasionally two techniques may be combined.

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FIG. 3.

Loop closure: PDS loop around breach in posterior right pleura.

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FIG. 4.

Fat pad closure: small pleural defect “plugged” with sac material.

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FIG. 5.

Surgical mesh: wet mesh placed over a pleural breach.

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FIG. 6.

V'lock suture: closure.

The loop was utilized if a small hole could be easily grasped by the forceps and drawn into the loop. Alternatively, a large piece of hernial sac with minimal fat on it was “pasted” over the defect. Large amounts of fat in the mediastinum are avoided due to previous experience of fat necrosis causing a fibrotic esophageal stricture. Clips or a hemostatic sponge can work. Should one technique fail, an alternative can be sought. A large rent may be closed with barbed suture. Once closure is obtained, rapid lung re-expansion occurs as the CO₂ is reabsorbed.