LETTER
Hippokratia 2013, 1(1):94
Giorgakis E1,2, Fernandez-Diaz S2
1Division of Surgery & Interventional Science, University College, 2Department of Renal Transplantation, Royal London Hospital, London, UK
Keywords: Subcutaneous emphysema, donor nephrectomy
Corresponding Author: Emmanouil Giorgakis MD MRCS, Royal London Hospital, Whitechapel London, E1 1BB, UK, tel: +447447907922, e-mail: Emmanouil.giorgakis@bartshealth.nhs.uk, Emmanouil.giorgakis.12@ucl.ac.uk
Dear Editor,
During laparoscopy, CO2 insufflation can result in gaseous deposition in subcutaneous and deeper fascial layers. The pharyngeal tissues could potentially become grossly emphysematous, thus posing a threat to the airway patency post-extubation.
In our institution, an otherwise fit 63-year-old woman underwent transperitoneal hand-assisted laparoscopic donor nephrectomy. During the 2 hours of pneumoperitoneum her cardiovascular parameters and end-tidal CO2 remained normal. The intra-abdominal pressure was in the range of 12 mmHg. Intraoperatively, she was noted to have developed marked cervical emphysema expanding cephalad and to the trunk and limbs. Her arterial blood gas analysis remained normal. A portable chest radiograph showed extensive subcutaneous emphysema of neck and chest wall.
Post-nephrectomy she remained intubated until a leak sound could be heard after deflation of the tube cuff and her vocal cords could be visualized by means of laryngoscopy. No further action was rendered necessary and the gaseous collection was allowed to be spontaneously absorbed and exhaled. On next day her subcutaneous emphysema had completely resolved. The patient had no obvious diaphragmatic defect.
Diffuse subcutaneous emphysema is an extremely rare complication; Baron et al showed zero incidence in 200 cases1; Halgrimson observed it once over 2562 cases2.
This data suggest that it is either an under-reported complication or it seldom happens.
There is no significant difference in carbon dioxide elimination in patients who underwent transperitoneal laparoscopy compared to retroperitoneoscopy3. A non-randomized prospective study comparing retroperitoneal versus transperitoneal approaches concluded that subcutaneous emphysema was strongly and independently associated with a greater degree of CO2 absorption during laparoscopic surgery and it did not depend on the surgical approach4.
When cervicofacial emphysema occurs during laparoscopic procedures, laryngoscopy should be performed before tracheal extubation in order to avoid potential airway obstruction from potential associated pharyngeal emphysema5. Once a pharyngeal swelling has been excluded, the subcutaneous CO2 emphysema may be let resolved spontaneously.
Conflict of interest
The authors declare no conflict of interest.
References
1. Baron PW, Ben-Youssef R, Ojogho ON, Kore A, Baldwin DD. Morbidity of 200 consecutive cases of hand-assisted laparoscopic living donor nephrectomies: a single-center experience. J Transplant. 2012; 2012:121523.
2. Halgrimson WR, Camsen J, Mandell MS, Kelly MA, Kam I, Zimmerman MA. Donor complications following laparoscopic compared to hand-assisted living donor nephrectomy: an analysis of the literature. J Transplant. 2010; 2010: 825689.
3. Ng CS, Gill IS, Sung GT, Whalley DG, Graham R, Schweizer D. Retroperitoneoscopic surgery is not associated with increased carbon dioxide absorption. J Urol. 1999; 162: 1268-1272.
4 Kadam PG, Marda M, Shah VR. Carbon dioxide absorption during laparoscopic donor nephrectomy: a comparison between retroperitoneal and transperitoneal approaches. Transplant Proc. 2008; 40; 1119-1121.
5 Yagihashi Y, Okinami T, Fukuzawa S. [Case of pharyngeal emphysema with airway obstruction during retroperitoneal laparoscopic nephroureterectomy]. Nihon Hinyokika Gakkai Zasshi. 2009; 100: 540-544.