Laparoscopic cholecystectomy in a patient with honey comb lung

Laparoscopic surgery of the gallbladder has increasingly replaced open tech niques due to postoperative benefits (less pulmonary complications, less po stoperative pain, earlier mobilisation). Specific intraoperative effects of pneumoperitoneum have led to some uncertainty if cardiac and/or pulmonary high-risk cases should be done laparoscopically. We describe anaesthesiolog ical management of a 72 year old patient with a unilateral leftsided honeyc omb lung (two very large cysts) to undergo laparoscopic cholecystectomy. vi tal capacity was reduced to 45%, forced expiratory 1 second Volume to 41%, praoperative bloodgas analysis revealed a paO(2) of 64 mmHg and a paCO(2) o f 40 mmHg. Under spontaneous breathing the patient was fiberoptically intub ated with a left sided double lumen tube (Mallinckrodt, Athlone/lrland;37 C h) using balanced anaesthesia. The healthy right lung was hand ventilated w ith 100% oxygen to avoid excessive airway pressures (peak airway pressure 2 7 mbar, mean airway pressure 22-24 mbar). The diseased left lung was passiv ely insufflated with oxygen. The intraabdominal pressure was limited to 10 mmHg. Muscle relaxation was achieved with atracurium under monitoring using a nerve stimulator. The paCO(2) increased from 40 to 57 mmHg during the op eration, but returned to normal immediately postoperatively. All other vent ilatory a nd hemodynamic parameters were uneventful during the 35 minute pr ocedure. The patient was extubated at the end of the procedure and monitore d on the intensive care ward for one night. A postoperative chest X-ray rev ealed a mediastinal shift of 2 cm to the right, healthy side as well as an atelectasis on this side. The shift was most: likely due to hypoventilation of the right lung,with the ensuing atelectasis drawing the mediastinum to the right. Under physiotherapy this shift had resolved by the next morning. The patient could be discharged from hospital on day seven and fully recove red. Especially the severely cardiopulmonary compromised patient benefits f rom a laparoscopic procedure, due to less postoperative reduction of pulmon ary function. Careful and individually adapted monitoring and anaesthetic t echniques are necessary to successfully counteract the special implications of pnemoperitoneum.