Laparoscopic appendicectomy in a postpneumonectomy patient.

Pneumoperitoneum for laparoscopic surgeries has anesthetic implications due to increase in the intra-abdominal pressure and end-tidal carbon dioxide. The effects are more pronounced if the patient has only one lung. However, the advantages of laparoscopy include reduced postoperative pain and early recovery. We present a case of 30-year-old patient who had undergone pneumonectomy and was posted for laparoscopic appendicectomy. General anesthesia was instituted, and with some modifications in ventilation, the procedure was uneventful and we were able to extubate the patient on the table. Understanding of the physiological consequences of pneumonectomy facilitated the provision of safe anesthesia.

INTRODUCTION

Laparoscopy is one of the most common surgical approach for appendicectomy.[1] However, pneumoperitoneum is associated with various cardiovascular and respiratory changes. Respiratory system changes are due to pneumoperitoneum and may get worsened by Trendelenburg positioning. This includes raised intrathoracic pressure, decreased functional residual capacity and pulmonary compliance, atelectasis, and impaired ventilation and perfusion.[2]

Pneumonectomy is a state of respiratory compromise with impaired oxygenation and ventilation. With improved survival rates, postpneumonectomy, there is an increased chance of these patients presenting for other surgical procedures.

Here is a case of a 30-year-old male with no other comorbidities, who underwent laparoscopic appendicectomy 8 years after left pneumonectomy.

CASE REPORT

A 30-year-old male weighing 43 kg (height: 160 cm, body mass index: 18) presented with a history of pain abdomen and fever for 1 day. He had undergone left pneumonectomy 8 years back for pulmonary tuberculosis. The patient's medical history was not suggestive of any other comorbidities. On examination, the patient was comfortable with a respiratory rate of 22/min and the left side of the chest appeared depressed. Auscultation of the chest showed good air entry with no added sounds on right side. No breath sounds were audible on the left side.

Preoperative hemoglobin was 15. Arterial blood gas analysis showed pH: 7.422, pCO2: 44 mm Hg, pO2: 88.9 mm Hg, SpO2: 96.1, and bicarbonate of 27.5 meq/l.

Preoperative chest X-ray showed white-out left hemithorax with mild expansion of the right lung and left hemidiaphragm appeared elevated [Figure 1].

Figure 1

Chest X-ray

The patient underwent laparoscopic appendicectomy under general anesthesia. After preoxygenation, the patient was premedicated with injection midazolam 1 mg and injection fentanyl 125 μg. Induction was done with injection propofol 50 mg. After administration of atracurium 35 mg, direct laryngoscopy was done (Grade 1), and under vision, 8-mm size-cuffed oral endotracheal tube was secured. Mechanical ventilation was instituted with volume controlled mode, with a tidal volume of 5 ml/kg and respiratory rate of 16/min, with an added positive end expiratory pressure of 5 cm of water. Peak airway pressure recorded was 20–22 cm of water.

General anesthesia maintained with oxygen and air at 2:2 ratio and sevoflurane 2%. Carbon dioxide pneumoperitoneum was maintained at 14 mm of Hg. Saturation maintained around 96%–97% throughout the procedure. The patient was stable hemodynamically. Extubation was uneventful and the patient was shifted to postoperative ICU care for further monitoring. He was transferred to general surgery ward the next day. Postoperative period was uneventful.

DISCUSSION

Pneumonectomy is indicated for many lung conditions. Following the procedure, there is a risk for cardiac and pulmonary complications. During the postoperative pneumonectomy period, there can be filling of air in the empty spaces and eventually the space gets filled with fluid. The normal lung can become hyperinflated and there can be mediastinal shift also.[3]

Ventilatory and cardiovascular changes such as increase in pulmonary vascular resistance and decreased stroke volume also can occur.[4]

Ventilatory effects of laparoscopic surgery include reduced lung compliance and ventilation perfusion mismatch, leading to hypoxia and hypercarbia. Cardiac effects include increased right atrial pressure and decreased cardiac output. This can be more pronounced in patients with pneumonectomy.[5] Our patient has undergone left-sided pneumonectomy in which the chance of left ventricular failure was high. We had introduced lung protective strategy in ventilating the patient with low tidal volume and high respiratory rate. This also helped in washing out the carbon dioxide that can accumulate over a period of time. Another concern was managing increase in peak airway pressure, due to abdominal insufflation and one lung ventilation. Our patient's peak airway pressure increased to 22 cm of water. However, with adequate paralysis and low tidal volume, we were able to overcome this.

The patient was hemodynamically stable, and oxygen saturation was also maintained throughout the procedure. The procedure was uneventful and we were able to extubate the patient on the table.

CONCLUSION

A proper knowledge of respiratory and cardiovascular changes is required before instituting anesthesia for post a pneumonectomy patient. In our experience, with the present case, we propose that laparoscopic appendicectomy is feasible and safe option in patients with a single lung.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.