Prevention

If a diaphragmatic or pleural injury is recognized intraoperatively, the anesthesiologist should be notified immediately. Usually, with careful adjustment of ventilatory parameters, the patient remains clinically stable, allowing completion of the proposed laparoscopic procedure and repair of the diaphragmatic rent.

During transperitoneal laparoscopy, care should be taken not to injure the diaphragm while mobilizing the spleen and liver.

During port placement for retroperitoneal laparoscopy in obese patients, whenever the bony landmarks are not clearly identifiable, intraoperative ultrasonography can be employed to precisely locate the 12th rib, thus avoiding inadvertent supracostal port placement (12). When creating the retroperitoneal space, the balloon dilator should be positioned anterior to the psoas muscle and fascia. This maneuver prevents

Due to the high solubility of CO2, in the select clinically stable patient with pneumothorax, pneumopericardium, and pneumomediastinum expectant management including close monitoring and serial chest X-rays is advocated.

Clinically significant pneumothorax may require intraoperative or early postoperative intervention.

If a diaphragmatic or pleural injury is recognized intraoperatively, the anesthesiologist should be notified immediately. Usually, with careful adjustment of ventilatory parameters, the patient remains clinically stable, allowing completion of the proposed laparoscopic procedure and repair of the diaphragmatic rent.

A blunt tip trocar can be used as the primary port to prevent subcutaneous emphysema.

Full relaxation of the abdominal muscles, as well as avoidance of coughing and straining during laparoscopic procedures is additional precautions to prevent abnormal thoracic gas collections during transperitoneal and retroperitoneal laparoscopy.

stripping the psoas muscle of its investing fascia, and minimizes cephalad tracking of CO2 along the psoas muscle fibers into the thoracic cavity (4).

A Blunt tip trocar can be used as the primary port to prevent subcutaneous emphysema.

This trocar has an internal fascial retention balloon and an external adjustable foam cuff, which combine to achieve an air-tight seal, thus eliminating air leakage at the primary port site.

Full relaxation of the abdominal muscles, as well as avoidance of coughing and straining during laparoscopic procedures is additional precautions to prevent abnormal thoracic gas collections during transperitoneal and retroperitoneal laparoscopy (13).

These precautions avoid sudden elevations of abdominal pressure above 20mmHg, which may potentially force abdominal CO2 through the diaphragmatic hiatus into the mediastinum.

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