Postoperative pneumoperitoneum after colorectal surgery: Expectantvssurgical management

Abstract

Postoperative pneumoperitoneum poses a clinical dilemma. Depending on the cause, its management includes a spectrum from simple observation and supportive care to surgical exploration. The aim of this paper is to present four clinical cases and propose an algorithm for the management of postoperative pneumoperitoneum based on available literature. The causes, diagnosis and possible complications arising from pneumoperitoneum will also be discussed. Three of the four cases presented were successfully managed conservatively and one had an exploratory laparotomy with negative findings. In such scenarios, it is important to consider the nonsurgical causes of pneumoperitoneum, which include pseudopneumoperitoneum, thoracic, abdominal, gynecological and idiopathic. These causes do not always require emergent exploratory laparotomy. The surgical team needs to consider the history, physical exam and diagnostic workup of the patient. If a patient presents with peritoneal signs, then exploratory laparotomy is a must. Since 10% of the cases of pneumoperitoneum are caused by nonsurgical entities, managed expectantly, a negative exploratory laparotomy and its associated risks are avoided.

Spontaneous pneumoperitoneum with duodenal diverticulosis in an elderly patient: a case report

“…Gynecological causes include sexual activity or spa jet-induced pneumoperitoneum [3,10]. The iatrogenic causes include endoscopic procedures and a postsurgical state [11].…”

Spontaneous pneumoperitoneum in pediatric patients: A case series

“…Subclinical perforations may be a common route for the development of idiopathic pneumoperitoneum, but these perforations are thought to resolve without surgical intervention [13] . In the setting of obstruction, pneumoperitoneum has been proposed to develop via dissection of air through a distended intestional wall [14] .…”

Gastrointestinal Ultrasound (GIUS) in Intestinal Emergencies – An EFSUMB Position Paper

“…In the postoperative situation, interpretation of free abdominal gas is difficult. Pneumoperitoneum usually can be visible for 2-5 days after surgery and sometimes may be observed for several weeks, but the amount of gas usually decreases with time [77,[88][89][90][91]. Postoperative pneumoperitoneum is more prevalent in asthenic patients, in the presence of intraperitoneal drains, and after open laparotomy compared with laparoscopy [89].…”

“…Postoperative pneumoperitoneum is more prevalent in asthenic patients, in the presence of intraperitoneal drains, and after open laparotomy compared with laparoscopy [89]. The clinical setting is crucial for deciding if intraperitoneal air is due to a ruptured hollow viscus, an intraabdominal abscess or residual gas after operative intervention [89,91]. An increasing amount of gas, imaging signs of peritonitis, elevated inflammatory parameters and clinical deterioration indicate complications [84,91].…”

“…The clinical setting is crucial for deciding if intraperitoneal air is due to a ruptured hollow viscus, an intraabdominal abscess or residual gas after operative intervention [89,91]. An increasing amount of gas, imaging signs of peritonitis, elevated inflammatory parameters and clinical deterioration indicate complications [84,91]. However, postoperative residual gas in the peritoneal cavity provides a good opportunity for training in the GIUS examination technique.…”