When carbon dioxide is used to insufflate the peritoneal cavity during laparoscopic surgery, the gas can dissect along tissue planes to collect in the subcutaneous tissue or pleural cavity. Early recognition of these gas collections are important to prevent serious complications.
Findings
Subcutaneous Emphysema
Capnothorax (CO2 pneumothorax)
end tidal carbon dioxide tension
increased
increased
pulse oximetry
unchanged
unchanged if minor, oxygen desaturation if larger
airway pressure
unchanged
increased
reduced air entry
no
yes
hyperresonance over hemithorax
no
yes
swelling and crepitus
yes
absent if pure
radiographs
gas in subcutaneous tissue
displaced lung; in severe cases the mediastinum may be shifted
If subcutaneous emphysema is noted:
(1) exclude concurrent capnothorax
(2) with involvement of the neck monitor the upper airway for obstruction
(3) increase ventilation to lower the PaCO2
If capnothorax is noted:
(1) discontinue the insufflation
(2) thoracentesis can usually be avoided since the pneumothorax will resolve spontaneously when insufflation is discontinued. However, it may be necessary in severe cases.
(3) increase ventilation to lower the PaCO2 and improve oxygenation
(4) apply positive end-expiratory pressure (PEEP)
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