Pneumomediastinum, pneumothorax and subcutaneous emphysema complicating MIS herniorrhaphy

Purpose: Videoscopic herniorrhaphy is being performed more frequently with advantages claimed over the conventional open approach. This clinical repor t describes a pneumothorax, pneumomediastinum and subcutaneous emphysema oc curring at the end of an extraperitoneal videoscopic herniorrhaphy. Clinical Features: A 25 yr old ASA I man presented for elective extraperito neal videoscopic hernia repair. Following intravenous induction with fentan yl, midazolam and propofol a balanced anesthetic technique using enflurane in N2O and O-2 was used. Apart from a prolonged operating time (195 min), t he procedure and anesthetic was uneventful. At the conclusion of the operat ion, prior to reversal of neuromuscular blockade extensive subcutaneous emp hysema was noted on removal of the surgical drapes. Chest radiography revea led a pneumomediastinum and pneumothorax, A 25 FG intercostal tube was inse rted and connected to an underwater seal drain. Sedation and positive press ure ventilation was maintained overnight to permit resolution and avoid air way compromise. The clinical and radiological features had resolved by the next morning and the patient's trachea was -extubated. His subsequent recov ery was uneventful. Conclusion: Pneumothorax and pneumomediastinum are well recognised complica tions of laparoscopic techniques but have not been described following extr aperitoneal herniorrhaphy. In this report we postulate possible mechanisms which may have contributed to their development, including inadvertent brea ch of the peritoneum and leakage of gas around the diaphragmatic herniae or tracking of gas retroperitoneally. The case alerts us to the possibility o f this complication occurring in patients undergoing videoscopic herniorrha phy.