Intra-operative Pneumothorax Complicating Laparoscopic Roux-en-Y Gastric Bypass

Background: Intra-operative pneumothorax (PTX) is an infrequent complication of laparoscopic surgery. Most cases are attributed to CO₂ diffusion across congenital diaphragmatic defects and resolve spontaneously. We report a case of PTX during a laparoscopic Roux-en-Y gastric bypass (LRYGBP). When applied to this specific patient population, the current literature recommendations for the management of intra-operative PTX are questioned. Material and Methods: A retrospective chart review of 400 consecutive LRYGBP procedures performed over a 30-month period revealed 1 case of PTX (0.025%). Results: A bulging left diaphragm, hypotension, bradycardia, decreased pO₂, and elevated EtCO₂ and airway pressures, were noted early in the case. She initially responded to conservative management but required multiple subsequent hospital admissions for pulmonary complications. Conclusions: Pneumoperitoneum-induced PTX during laparoscopic bariatric surgery is a rare complication. Its treatment must be based on the potential underlying cause, with consideration of these patients' often delicate pulmonary status. In stable patients, where the PTX is attributed to diaphragmatic or hiatal dissection, expectant treatment is appropriate. In all other situations, however, we believe that tube thoracostomy is indicated. An algorithm for treatment of PTX in laparoscopic bariatric surgery is proposed. It follows the dictum of maintaining extreme vigilance and a low threshold for aggressive intervention in this group of patients.