Massive Upper Body and Cervicofacial Subcutaneous Emphysema Following Robotic Myomectomy

Abstract

Subcutaneous emphysema is defined as the unintentional introduction of air or carbon dioxide in the subcutaneous tissues. The use of robotic surgical techniques has greatly expanded over the past decade specifically to treat intraperitoneal pathology. In general, advantages of these minimally invasive procedures are reported to decrease operating time, patient morbidity, and shorten hospital stay providing a safe alternative to traditional surgery. However, as with any surgery, potential complications may occur. We describe an unusual case of massive subcutaneous emphysema involving the upper body and cervicofacial region, with bilateral pneumothoraces following robotic intraperitoneal surgery. Written authorization was obtained from the patient.

The Development of Extensive Subcutaneous Emphysema Following Robotic Total Abdominal Colectomy Due to Lynch Syndrome: A Case Report

“…The pathogenesis of subcutaneous emphysema has been attributed to multiple possible causes, such as malfunctions in ventilator circuits or pop-off valves, trauma to the airway, chest wall or bowel, or following insufflation of the abdomen during laparoscopic or robotic procedures [2]. In severe cases, complications such as delayed extubation, pneumomediastinum, pneumoperitoneum, and pneumothorax may occur due to extravasation of air into other bodily spaces from pressure gradients between anatomic and fascial planes [1,6,11]. In this case, it is our belief that the likely cause of diffuse subcutaneous emphysema was the placement of trocars and insufflation of the abdomen for the robotic total colectomy.…”

“…The CT scans of the neck and chest obtained following transfer to the ICU revealed no evidence of trauma to the airway or injury to the esophagus, and there were no intraoperative surgical complications. Studies have demonstrated that the risk of subcutaneous emphysema following robotic-assisted laparoscopic surgery is greater in older patients, lengthy surgical procedures with more than five entry ports, and with the utilization of high CO 2 insufflation pressures (e.g., 15-20 mmHg) [11]. The extent of subcutaneous emphysema is typically described as "mild," "moderate," or "massive," which refers to the presence of crepitus at the trochar insertion sites, extending to the abdomen, or extending to the chest, neck, face, and extremities, respectively [11].…”

“…Studies have demonstrated that the risk of subcutaneous emphysema following robotic-assisted laparoscopic surgery is greater in older patients, lengthy surgical procedures with more than five entry ports, and with the utilization of high CO 2 insufflation pressures (e.g., 15-20 mmHg) [11]. The extent of subcutaneous emphysema is typically described as "mild," "moderate," or "massive," which refers to the presence of crepitus at the trochar insertion sites, extending to the abdomen, or extending to the chest, neck, face, and extremities, respectively [11]. In robotic-assisted laparoscopic surgeries, subcutaneous emphysema usually develops due to the dissection of tissue around the trocar sites while attempting to insert or remove the ports or due to high insufflation pressures [11].…”

Tips for set-up to prevent complications in robotic gynecologic cancer surgery

“…Subcutaneous emphysema (SCE) was rarely reported in gynecologic surgery [13][14][15][16]. Extrapolating the experience from laparoscopic surgery, risk factors for SCE include multiple abdominal entries, long operative times of ≥200 minutes, five or more laparoscopic ports, and age older than 65 years [17,18].…”

Quantitative Analysis of Hypercarbia and Ventilator Settings During a Robot Assisted Laparoscopy

“…However, the exact incidence of SE in robotic surgery is not known, moreover, ndings of SE can be delayed and the typical end-tidal carbon dioxide ( elevation on the ventilator is not seen in all cases. [2].…”