Unilateral periorbital emphysema recognized intraoperatively in laparoscopic low anterior resection surgery

19AP12-10
Unilateral periorbital emphysema recognized intraoperatively in laparoscopic low anterior resection surgery

K.S. Elden1, B.S. Yurtlu1

1Dokuz Eylul University Research and Application Hospital, Anesthesiology Department, Izmir, Turkey

Background: Intraoperative and postoperative subcutaneous emphysema in the cervical, thorax and abdomen are common complications of laparoscopic surgery. However, cases of uni- lateral periorbital subcutaneous emphysema are very rare in the literature. In this case report, we emphasize a patient who developed unilateral periorbital emphysema due to hypercarbia and acidosis.

Case Report: The patient was an ASA 2, BMI:23, 67-year-old woman with a history of colonoscopy. Preoperative vital signs, tests and physical examination were normal.

Anesthesia induction was achieved with dormicum 2 mg, fentanyl 2 mg/kg, rocuronium 0.5 mg/kg and endotracheal intubation was performed. Both lungs were participating equally in respiration. Anesthesia was maintained with 1-3% sevoflurane and 50% O2. The patient in supine position was given 45 degrees Trendelen- burg, right tilt position.

Laparoscopic trocars were placed in umbilicus, lower right, upper right and upper left quadrants. Pneumoperitoneum was created with carbon dioxide insufflation (15mmHg).
At the 3rd hour of the operation, edema in the left periorbital re- gion and crepitation with palpation were noticed.

Bilateral crepitation was also detected in the neck and thoracic region. Both lung sounds were equal. ETCO2 was 35mmHg at the beginning of the operation and ETCO2 was 50mmHg at the 3rd hour.

Respiratory acidosis was observed in the ABG. The number of respirations per minute was increased. After 3.5 hours, laparoto- my was started and lasted 5.5 hours. The patient was transferred to PACU.

Discussion: Philips et al. 600 found a 2% rate of subcutaneous emphysema in laparoscopic complications(1).
Periorbital emphysema is caused by disruption of the integrity of the orbital walls and is most commonly associated with orbital and sinus fractures(2).

Mostly periorbital emphysema resolves spontaneously in a few days. It does not cause visual impairment. Hyperventilation until normocarbia is achieved helps to reduce advanced acidosis. References:

1. Philips PA, Amaral JF. Abdominal access complications in laparoscopic surgery Journal of the American College of Surgeons. 2001;192(4):525- 36.
2. Aggarwal NK, Meyer D. Massive periorbital emphysema associated with laparoscopic nephrectomy. Ophthal Plast Reconstr Surg 2004; 20(5): 394-5.
Learning Points: Close intraoperative anesthesia observation al- lows early recognition of complications of laparoscopic surgery.