Sir,Subcutaneous emphysema (SCE), also called surgical emphysema, is the sudden onset soft tissue swelling arising when gas is forced under pressure into the subcutaneous fascia because of myriad causes (pneumothorax, ruptured bronchus, facial bone fracture, paranasal sinus pathology, playing a wind instrument after dental extraction, vigorous nose-blowing, coughing, or Valsalva maneuver).[12] We have encountered different degrees of SCE in more than 30 out of over 3000 patients who underwent robotic surgery (hysterectomies and cystoprostatectomies) at our institution. Despite a high incidence rate (2.3% in laparoscopic vaginal hysterectomies, Murdoch et al.),[3] no definite management guidelines exist. The gas used for pneumoperitoneum often dissects into the deeper soft tissues and musculature along the fascial planes. A recent case, where SCE had reached the ipsilateral wrist of the patient starting from the groin (site of surgery), prompted us to develop and present an algorithm [Figure 1] for the management of this condition.
Figure 1
Algorithm for the management of intraoperative subcutaneous emphysema during robotic surgery
Algorithm for the management of intraoperative subcutaneous emphysema during robotic surgeryOur patient was a 45-year-old, 60 kg male diagnosed with carcinoma penis. He was posted for partial penectomy and bilateral robotic video endoscopic inguinal lymph node dissection. Half an hour after pneumoperitoneum and docking of the “daVinci Xi” surgical robot, the end-tidal carbon dioxide (EtCO2) started steeply rising. The tidal volume was increased in increments of 50 ml to 10 ml/kg body weight while the respiratory rate was increased to 18 breaths per minute in an attempt to wash away the excess CO2 by increasing the minute ventilation. Ventilatory settings were in a volume-controlled mode with inspiratory–expiratory ratio of 1:2. The EtCO2 rapidly rose to 67 mmHg. On examination, surgical emphysema was palpable (crepitus) not just over the abdomen, trunk, and neck but also in the axillary region. The pneumoperitoneum pressure was reduced from 15 mmHg to 8 mmHg. When the right radial artery was palpated for obtaining a sample for arterial blood gas analysis, frank crepitus was also observed over the wrist. On applying digital pressure, pitting was observed. The skin could be seen to slowly rise back as it was filled up with gas again. A wide bore needle was used to extract the CO2 from the infraclavicular region. CO2 could be seen bubbling through the saline-filled syringe on aspiration. Finally, the surgery was halted and the patient was placed in Trendelenburg position in an attempt to vent out the CO2 using the Archimedes' principle. The arterial blood gas (ABG) (sampled when EtCO2 was 55 mmHg) showed a partial pressure of CO2(PaCO2) of 68 mmHg. The surgery was resumed once the EtCO2 dropped to below 45 mmHg as CO2 got absorbed from the interstitial tissue. A check laryngoscopy and leak-test were done to make a decision regarding extubation, although crepitus could still be felt in the supramammary area.Usually, benign and self-limiting, extensive SCE can cause palpable cutaneous tension, abdominal compartment syndrome, dysphagia, dysphonia, palpebral closure, pacemaker dysfunction, airway compromise, and respiratory failure.[45] Our algorithm describes four bundles comprising both conservative and surgical management techniques, helpful in tackling all degrees and stages of surgical emphysema, which complicate robot-assisted urogynecological surgery.[145] The first three bundles fall in the anesthesiologists' domain who should be eternally vigilant for SCE during robotic surgery.
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Figure 1