CASE REPORT

Pneumomediastinum After Robotic Sacrocolpopexy Natalie M. Crawford, MD, Sujatha D. Pathi, MD, and Marlene M. Corton, MD

Background: Pneumomediastinum is a rare but potential complication of laparoscopy that is related to insufflation with carbon dioxide gas and may lead to life-threatening complications. Case: A 76-year-old woman underwent robotic sacrocolpopexy to repair posthysterectomy prolapse without any apparent intraoperative complications. Postoperatively, she developed shortness of breath and tachycardia and was found to have subcutaneous emphysema and pneumomediastinum. Conclusion: Pelvic surgeons should understand the risks associated with development of pneumomediastinum as well as associated signs and symptoms. In our case, pneumomediastinum likely developed as carbon dioxide tracked from the peritoneum into the mediastinum during prolonged robotic retroperitoneal surgery. Surgeons should have a low threshold to obtain radiographic tests in the early postoperative period, as close monitoring is essential to manage potentially life-threatening complications such as pneumothorax and cardiac arrest. Key Words: pneumomediastinum, sacrocolpopexy, robotic surgery (Female Pelvic Med Reconstr Surg 2014;20: 56Y58)

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aparoscopy is now the standard approach for many gynecologic surgeries owing to faster recovery time and improved cosmetic results compared to traditional laparotomy.1 Robotic laparoscopy is increasing in popularity. Reasons often cited for the widespread use of this approach include improved operative dexterity and enhanced visualization. However, robotic surgery has a large learning curve and is frequently associated with a longer operating time compared to traditional laparoscopy.1 Both laparoscopy and robotic-assisted laparoscopy have unique complications associated with insufflation of the peritoneal space with carbon dioxide (CO2) gas. These complications include cardiac arrhythmias, pneumomediastinum, and pneumothorax, all of which can be fatal if not identified and managed appropriately.2 We present a case of a woman who unexpectedly developed subcutaneous emphysema and pneumomediastinum after a robotic sacrocolpopexy.

CASE A 76-year-old white woman with a history of hypertension and hypothyroidism presented with bothersome posthysterectomy apical prolapse for which she desired surgical management. The surgical approaches, including laparotomy, laparoscopy, and robotic-assisted laparoscopy, were reviewed with the From the Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX. Reprints: Natalie M. Crawford, MD, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75235-9032. E-mail: [email protected] The authors have declared that they have no conflicts of interest. Copyright * 2013 by Lippincott Williams & Wilkins DOI: 10.1097/SPV.0b013e31829098b9

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patient; and the decision was made to proceed with robotic sacrocolpopexy. The patient was taken to the operating room by the urogynecology service for robotic sacrocolpopexy. The total operating time was 5 hours and 40 minutes, and no concomitant procedures were performed. The specific time required for each step of the case was not recorded. No difficulty or trauma during intubation was reported. A total of 5 ports were used: 3 robotic operative ports, 1 laparoscopic assistant port, and 1 robotic camera port. The patient was placed in steep Trendelenburg position, and pneumoperitoneum was maintained at less than 15 mm Hg throughout the case. All dissections and suturing were performed robotically. The case proceeded in routine fashion without any apparent surgical or anesthetic complications. Anesthesia did not appreciate any abnormal physical examination findings throughout the case. However, in the postanesthesia care unit, the patient complained of shortness of breath and was noted to have a pulse of 130, respiratory rate of 30, and increased oxygen requirement. Her physical examination was significant for subcutaneous crackles throughout her upper chest and neck. A chest x-ray (Fig. 1) revealed significant subcutaneous emphysema and a right-sided pneumomediastinum. The patient was admitted to the intensive care unit, where she received supportive measures including supplemental oxygen and continuous cardiac monitoring. The pneumomediastinum resolved completely by the following morning, and there was marked improvement in her subcutaneous emphysema. The patient was then weaned off oxygen and subsequently transferred to the floor. The remainder of her hospital course was unremarkable, and she recovered from both her surgery and the pneumomediastinum.

DISCUSSION The mediastinum is composed of the tissues and organs between the sternum and vertebral column from the thoracic inlet superiorly to the diaphragm inferiorly. As the mediastinum contains the critical structures for proper cardiopulmonary function, alteration to this space can be life threatening. The mediastinum is not a confined space; it communicates with the submandibular space, the retropharyngeal space, the vascular sheaths of the neck, and the retroperitoneal space. The mediastinum communicates with the retroperitoneal space via the sternocostal attachment of the diaphragm and also the periaortic and periesophageal fascial planes.3 Potential air sources leading to the development of pneumomediastinum include both intrathoracic and extrathoracic etiologies. Examples of intrathoracic sources include direct trauma and alveolar rupture, whereas extrathoracic sources would result from the dissection of air from one of the communicating spaces mentioned previously.3 Pneumomediastinum is a relatively rare complication of laparoscopy. Proposed mechanisms for the development of pneumomediastinum during surgery include trauma associated with intubation, specific type of surgery performed, individual patient anatomy, and improper port placement. Incorrect trocar

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Volume 20, Number 1, January/February 2014 Pneumomediastinum After Sacrocolpopexy

FIGURE 1. Pneumomediastinum and subcutaneous emphysema are present.

placement or trocar dislodgement can result in insufflation of the subcutaneous tissue with CO2 gas and potential tracking into the mediastinum.2 Furthermore, patients may have unrecognized small congenital diaphragmatic defects, such as a hiatal hernia, which may predispose them to leakage of the pneumoperitoneum into the mediastinum during laparoscopy.4 The occurrence of pneumomediastinum after laparoscopic surgery has been reported in several retrospective case series. Richard et al5 retrospectively reviewed 722 laparoscopic cases for evidence of postoperative pneumomediastinum. These cases included esophageal hernia repair, cholecystectomy, bowel resection, and salpingo-oophorectomy. Of the 10% of the patients who had a postoperative chest x-ray, either routine after esophageal surgery or for cardiovascular indications, 10% of these showed evidence of pneumomediastinum. All cases were discovered on postoperative day number one, and none required surgical intervention. No cases of pneumomediastinum were reported with the gynecologic procedures in this review. Abreu et al4 reviewed 1129 urologic laparoscopies performed at the Cleveland Clinic between 1997 and 2001. Of 619 patients (54.8%) who had postoperative chest x-rays, most of which were routine chest x-rays done after all laparoscopic surgeries in the first few years of the study, 9.5% had evidence of pneumomediastinum. Of these, 93% had undergone retroperitoneal surgery. None of these patients had additional cardiac complications or required further surgical intervention. The authors concluded that the most likely route for the development of pneumomediastinum during retroperitoneal laparoscopic surgery was the cephalad tracking of CO2 gas near the aorta and vena cava.4 Whereas the aforementioned studies focused on the frequency of pneumomediastinum in laparoscopic surgery, Murdock et al2 sought to determine risk factors for its etiology. They reviewed all laparoscopic surgeries performed at a single institution in 1 year to identify risk factors for hypercarbia, pneumothorax, and pneumomediastinum. Risk factors examined included age, body mass index, number of surgical ports, operative time, positive * 2013 Lippincott Williams & Wilkins

end-tidal CO2, sex, type of surgery, use of open entry technique, medical history, and preperitoneal insufflations. Intra-abdominal pressure setting and the use of the Trendelenburg position were not assessed. Of the 968 laparoscopic cases reviewed, 1.9% had pneumothorax and/or pneumomediastinum. Risk factors included an increased operative time (9200 minutes), greater number of ports (6 or more), older age (965 years), increased end-tidal CO2, and Nissen fundoplication surgery. No cases of pneumothorax or pneumomediastinum were identified in the 233 gynecologic cases performed in this series.2 Robotic-assisted laparoscopy is often associated with longer operating time compared to the traditional laparoscopic and open approaches. A retrospective study that compared robotic sacrocolpopexy with abdominal sacrocolpopexy demonstrated a significantly longer operating time for robotic sacrocolpopexy, 328 minutes compared to 225 minutes.6 A retrospective comparison of robotic sacrocolpopexy and laparoscopic sacrocolpopexy also demonstrated significant increase in operative time with robotic sacrocolpopexy, 281 minutes compared to 206 minutes.7 A recent randomized controlled trial confirmed the significant increase in operating time with robotic sacrocolpopexy compared to laparoscopic.8 In this study, the mean operating time with robotic sacrocolpopexy was 265 minutes, compared to 199 minutes, with the traditional laparoscopic approach. However, the studies cited do not always take into consideration the learning curve associated with robotic surgery, and it should be kept in perspective that a more experienced surgeon will often have a faster operating time compared to one who is less experienced. Based on the previous studies, we identified multiple potential factors that could have led to the development of a postoperative pneumomediastinum in our patient including age older than 65, prolonged operative time (342 minutes), and retroperitoneal surgery. The prolonged operating time associated with robotic sacrocolpopexy in comparison to traditional approaches has been consistently demonstrated.1,6Y8 This increase in operating time may lead to subcutaneous emphysema and pneumomediastinum, as CO2 absorption seems to increase with surgical duration.2,4 In addition, sacrocolpopexy procedures require retroperitoneal entry and dissection; thus, a direct pathway for cephalad migration of CO2 into the mediastinal space existed. No studies to date have evaluated the impact of steep Trendelenburg position on the development of pneumomediastinum. In our patient, we hypothesize that prolonged retroperitoneal surgery in the steep Trendelenburg position led to sustained increased pressure on the diaphragm and increased the risk of CO2 extravasation into the mediastinum. Pneumomediastinum is a relatively rare but potentially serious complication of laparoscopic surgery. Pneumomediastinum can lead to obstruction in the venous return to the heart, which can lead to cardiac arrest. Furthermore, pneumomediastinum is also closely associated with the development of pneumothorax, which displaces the lungs and requires acute intervention with immediate chest tube placement to avoid cardiac decompensation. As CO2 gas has a high tissue solubility, management of a pneumomediastinum is expectant with close continuous monitoring of cardiopulmonary function. Our patient’s symptoms improved with high-flow oxygen, and she only required an overnight admission to the intensive care unit for continuous cardiac monitoring. Although no previous studies report pneumomediastinum after gynecologic surgery, as robotic gynecologic surgery increases in popularity, surgeons should be aware of potential risk factors for the development of pneumomediastinum. Both the retroperitoneal nature of the surgery and the longer insufflation time associated www.fpmrs.net

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with robotic sacrocolpopexy may increase the potential for pneumomediastinum development. Therefore, surgeons need to understand the preoperative and intraoperative factors that increase the risk of pneumomediastinum. Close observation for signs and symptoms of this condition in the immediate postoperative period is warranted, and surgeons should have a low threshold for radiographic tests that would allow prompt detection and appropriate management. REFERENCES

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3. Zylak CM, Standen JR, Barnes GR, et al. Pneumomediastinum revisited. RadioGraphics 2000;20:1043Y1057. 4. Abreu AC, Sharp DS, Ramani AP, et al. Thoracic complications during urological laparoscopy. J Urol 2004;171:1451Y1455. 5. Richard HM, Stancato-Pasik A, Salky BA, et al. Pneumothorax and pneumomediastinum after laparoscopic surgery. Clin Imaging 1997;21:337Y339. 6. Gellar EJ, Siddiqui NY, Wu JM, et al. Short-term outcomes of robotic sacrocolpopexy compared with abdominal sacrocolpopexy. Obstet Gynecol 2008;112:1201Y1206.

1. Visco AG, Advincula AP. Robotic gynecologic surgery. Obstet Gynecol 2008;112:1369Y1384.

7. Tan-Kim J, Menefee SA, Luber KM, et al. Robotic-assisted laparoscopic sacrocolpopexy: comparing operative times, costs and outcomes. Female Pelvic Med Reconstr Surg 2011;17:44Y49.

2. Murdock CM, Wolff AJ, Geem TV. Risk factors for hypercarbia, subcutaneous emphysema, pneumothorax, and pneumomediastinum during laparoscopy. Obstet Gynecol 2000;95:704Y709.

8. Paraiso MF, Jelovsek JE, Frick A, et al. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse. Obstet Gynecol 2011;118:1005Y1013.

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Pneumomediastinum after robotic sacrocolpopexy.

Pneumomediastinum is a rare but potential complication of laparoscopy that is related to insufflation with carbon dioxide gas and may lead to life-thr...
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