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| CASE REPORT |
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| Year : 1990 | Volume
: 36
| Issue : 1 | Page : 31-2 |
Pneumoperitoneum and pneumomediastinum: unusual complications of laparoscopy.
Shah PP, Ramakantan RR
Dept. of Radiology, K.E.M. Hospital, Parel, Bombay, Maharashtra.
Correspondence Address:
Dept. of Radiology, K.E.M. Hospital, Parel, Bombay, Maharashtra.
Pneumoretroperitoneum and pneumomediastinum are rare complications of laparoscopy. We report one such case. The mechanism of development of these complications is explained. No specific treatment needs to be instituted in most of these patients.
How to cite this article:
Shah P, Ramakantan R. Pneumoperitoneum and pneumomediastinum: unusual complications of laparoscopy. J Postgrad Med 1990;36:31 |
We present a case of pneumoretroperitoneum and pneumomediastinum following diagnostic laparoscopy. Though well known, this complication is rare. The mechanism of spread of pneumoperitoneum to the retro-peritoneum and mediastinum is not entirely clear.
A 25-year-old female was subjected to standard laparoscopy for investigation of primary infertility. Two litres of room air was used to induce pneumoperitoneum. The procedure was uneventful. Six hours following the procedure, the patient complained of retrosternal discomfort and hence chest radiography was obtained. A pneumomediastinum was detected on this radiograph. (See [Figure - 1]) An upright film of the abdomen was also done (See [Figure - 2]) to assess a possible pneumoretroperitoneum. The patient was treated symptomatically and was symptom-free at the end of 24 hours.
Complications of air insufflation as a part of laparoscopy include subcutaneous emphysema, omental emphysema, pneumoretroperitoneum and pneumomediastinum[4]. In a series of 4048 laparoscopies, pneumomediastinum occurred on one occasion at a complication rate of 0.02%[2]. Neither pheumoretroperitoneum nor pneumomediastinum have any clinical consequence in most of the patients. However, large amount of mediastinal air can produce symptoms due to obstruction of venous return to the heart. Mediastinal emphysema can also result into pneumothorax[3].
The peritoneal cavity is a closed space with no constant communication with the mediastinum or the retroperitoneum. On the other hand, the retroperitoneum and the mediastinum communicate with each other through the oesophageal and aortic hiatus[6].
It is easy to explain the development of pneumoperitoneum following pneumoretroperitoneum[1]. As more and more air accumulates within the potential cavity of the retroperitoneum, the intraperitoneal pressure increases leading to perforation of a weak portion of the mesentery or the parietal peritoneum[1].
On the other hand, it is difficult to explain the development of pneumoretroperitoneum as a consequence of pneumo-peritoneum. It has been postulated that this occurs because of congenital or acquired peritoneal defect[6]. In patients undergoing laparoscopy, it is much more likely that pneumoretroperitoneum results because of faulty technique[5]. This happens when the needle is introduced too far deep into the abdominal cavity and air gets injected into the retroperitoneum. As explained before, this air then finds its way through the oesophageal and aortic hiatus into the mediastinum (See [Figure - 3] and [Figure - 4]).
It should be understood that pneumo-mediastinum as a consequence of pneumoperitoneum can occur independent of the development of pneumoretro-peritoneum; however, the mechanism for this is not clear[6].
| 1. |
Calenoff L, Poticha SM. Combined occurrence of retropneumoperitoneum and pneurnoperitoneum. Amer J Roentgenol 1973; 117:366-372.  |
| 2. | Khandwala SD. In: 'Practical laparoscopy', 1st edition, Mumbai: Bhalani Publishing House; 1984, pp 107. |
| 3. | Kleinman PK, Brill PW, Whalen JP. Anterior pathway for transdiaphragmatlic extension of pneumomediastinum. Amer J Roentgenol 1978; 131:271-275. |
| 4. | Saleh JW. In: "Laparoscopy". Philadelphia: WB Saunders Co.; 1988, pp 255. |
| 5. | Saleh JW. In, "Laparoscopy", Philadelphia: WB Saunders Co.; 1988, pp 257. |
| 6. | Towbin MN. Mediastinal emphysema occurring with therapeutic pneumoperitoneum: report of ten cases. Ann Int Med 1951; 35:555-592.
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