{"paper_id":"acd97de7-649c-4e89-ba22-21b2ffc65469","body_text":"C A S E R E P O R T Open Access\nTension pneumoperitoneum after surgery\nfor endometrial cancer and hernia in a\nmorbidly obese female: a case report\nBing-Sheng Lin 1, Yan-Shen Shan 2, Wan-Chen Liu 3, Chin-Han Wu 4, Pei-Ying Wu 4 and Keng-Fu Hsu 4*\nAbstract\nBackground: Obesity is a risk factor for the development of endometrial cancer and abdominal wall hernias. We\nreport a case of tension pneumoperitoneum that develo ped after gynecological surgery and mesh repair of a\nventral hernia.\nCase presentation: A 57-year-old Asian Taiwanese woman with a body mass index of 52.9 (kg/m 2) underwent\ntotal abdominal hysterectomy and bilateral salpingo- oophorectomy due to endometrial cancer, and ventral\nherniorrhaphy with mesh du e to ventral hernia. Tension pneumoperitoneum with severe dyspnea developed\non postoperative day 14. Rather than performing emergency laparotomy as in visceral perforation, a transabdominal\ncatheter was inserted to drain the intra-abdominal ga s. This approach dramatic ally relieved the tension\npneumoperitoneum and dyspnea. Our patient then recovered smoothly; the catheter was removed on postoperative\n24, and she was discharged on postoperative day 28. The clinical course of the endometrial cancer and repaired ventral\nhernia was well at the 1-year follow-up.\nConclusions: Tension pneumoperitoneum, which may result fr om the valve effect of unhealed abdominal mesh,\ncould develop after gynecological surgery and hernia mesh repair in obese patients. Under these conditions, emergency\ndrainage of the intra-abdominal gas by catheter insertion is sufficient to relieve the abdominal pressure and correct the\nconditions, while emergency laparotomy as in visceral perforation is unnecessary and may increase patient morbidities.\nKeywords: Tension pneumoperitoneum, Endometrial cancer, Hernia, Obesity\nBackground\nA high body mass index (BMI) is an established risk factor\nfor the development of endometrial cancer [ 1]. Obesity\npredisposes patients to abdominal wall hernias. Obese\npatients with a higher BMI undergoing abdominal wall\nrepair often have increased complications, including\nabdominal compartment syndrome, seroma, hematoma,\ninfectious morbidity, and dehiscence, which typically\noccur early in the postoperative period [ 2, 3].\nThe accumulation of free intra-abdominal air with\nelevated intra-abdominal pressure is known as tension\npneumoperitoneum (TP). TP may result in an elevation of\nthe diaphragm, which reduces lung volume and compresses\nthe inferior vena cava, which in turn reduces the venous\nreturn and cardiac output and can result in aortic occlusion\n[4]. Various etiologies have been reported, including\ngastrointestinal perforation, barotrauma in ventilated\npatients, and diaphragmatic hernia repair [ 5]. Here,\nwe report the case of a morbidly obese woman with\nTP that developed after surgery for endometrial cancer\nand the mesh repair of a ventral hernia. Rather than\nperforming emergency laparotomy as in visceral per-\nforation, she received drainage of the intra-abdominal\ngas by a transabdominal catheter which relieved the\nTP and her dyspnea.\nCase presentation\nA 57-year-old gravida 6, para 3, Asian Taiwanese woman\npresented to our hospital for scheduled surgery due to\nendometrial cancer. At admission, her body temperature\nwas 36.8 °C, pulse rate 78 beats/minute, respiratory rate\n* Correspondence: d5580@mail.ncku.edu.tw\n4Department of Obstetrics and Gynecology, National Cheng Kung University\nHospital, College of Medicine, National Cheng Kung University, 138 Sheng Li\nRoad, Tainan 704, Taiwan\nFull list of author information is available at the end of the article\n© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0\nInternational License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and\nreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to\nthe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver\n(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.\nLin et al. Journal of Medical Case Reports  (2018) 12:73 \nhttps://doi.org/10.1186/s13256-018-1581-7\n\n20/minute, and blood pressure 136/98 mmHg. Her\nfamily and environmental history were unremarkable.\nShe did not receive surgery before nor take any medication\nfor systemic disease, such as diabetes mellitus or\nhypertension. She was a housekeeper. She did not\nsmoke tobacco or consume alcohol. On physical\nexamination, she had normal breathing sound, without\nwheezing or crackle, and a regular heartbeat without\nmurmur. Her abdomen was soft with normoactive\nbowel sound on auscultation. Her extremities were\nfreely moveable without edema. She exhibited severe\nmorbid obesity (body weight, 128.4 kg; height, 155.7 cm;\nBMI, 52.9 kg/m 2). Her daily activities were independent\nmost of the time, except for some episodes of exertional\ndyspnea. Computed tomography (CT) revealed a ventral\nhernia with a large fascial defect (Fig. 1) .T h e r ew e r en o\nclinical symptoms, such as abdominal pain or tenderness.\nShe underwent total abdominal hysterectomy, bilateral\nsalpingo-oophorectomy, and ventral herniorrhaphy with\nGoretex mesh (GORE DUALMESH®).\nHer early postoperative course was smooth. She\nconsumed water on postoperative day (POD) 3, a clear-li-\nquid diet on POD5, and a semi-liquid diet on POD7.\nShe began bedside ambulation, and half of her stitches\nwere removed on POD10. However, progressive dyspnea\nwas noted after bedside ambulation. Intra-abdominal free\nair with elevation of right-side hemidiaphragm was noted\nby chest X-ray (Fig. 2a) on POD14. There was no ab-\ndominal tenderness or rebounding pain, but there was\nmoderate abdominal distension. She was kept under close\nobservation and began nil by mouth (NPO) for possible\nvisceral perforation.\nTwo days later (POD16), severe dyspnea and extensive\nabdominal distention were noted. Her respiratory rate was\nelevated to 26/minute with accessory muscle use. Arterial\nblood gas analysis (under simple O 2 mask, 10 L/minute)\nFig. 1 Computed tomographic image showing a large ventral hernia sac\nLin et al. Journal of Medical Case Reports  (2018) 12:73 Page 2 of 5\n\nshowed: pH, 7.42; partial pressure of carbon dioxide in\narterial blood (PaCO 2), 44.8 (mmHg); partial pressure of\noxygen in arterial blood (PaO2), 86.2 (mmHg); bicarbonate\n(HCO3-), 28.5 (mmol/L); blood oxygen saturation (SpO 2),\n96.7%; and blood pressure, 102/75 mmHg. Laboratory\ntests revealed leukocytosis with a white blood cell (WBC)\ncount of 12,900/uL, hemoglobin (Hb) 12.6 g/dL, and\nplatelet count 310,000/uL. Her C-reactive protein (CRP)\nwas elevated at 165.7 mg/dL. Serum creatinine was 0.99\nmg/dL, while serum sodium was 131 mmol/L, and potas-\nsium was 3.9 mmol/l. A physical examination showed\nsevere abdominal distension without rebound pain. A\npelvic examination demonstrated good healing of the\nvaginal cuff without leakage. CT showed a large amount\nof intra-peritoneal free air with little ascites (Fig. 2b).\nBecause clinical visceral perforation was less likely, under\nthe impression of pneumoperitoneum, in this emergent\nsituation, an 8-Fr. pigtail catheter was inserted under CT\nguidance for decompression. A massive amount of gas\nwas drained. Subsequently, her dyspnea and abdominal\ndistention dramatically subsided. She re-started oral intake\non POD20, and the abdominal pigtail catheter was removed\non POD24 after no more free air was revealed by\nchest X-ray. No further abdominal distention was noted,\nand she was discharged on POD28. The clinical course of\nthe endometrial cancer and repaired hernia were well at\nthe 1-year follow-up.\nDiscussion\nIn our case, the TP may have resulted from the valve ef-\nfect of unhealed hernia mesh. Unlike the TP caused by\ngastrointestinal perforation which needs emergency\nlaparotomy to repair the perforation, it was unnecessary\nfor our patient. The drainage of intra-abdominal free air\nis sufficient to improve this condition. The most common\niatrogenic cause of pneumoperitoneum is abdominal\nsurgery. Postoperative pneumoperitoneum is usually\nabsorbed within 2 weeks. When pneumoperitoneum\nprogresses with increasing intra-abdominal pressure,\nhemodynamic and ventilatory compromise might\noccur, and the condition results in TP. Dyspnea and\nvenous congestion in the lower extremities might be\nnoted during the physical examination. Similar to tension\npneumothorax, emergency percutaneous needle de-\ncompression is needed [ 6]. When managing hollow\norgan perforation-related TP , a venous catheter may\nbe percutaneously inserted to stabilize the patient ’s\nvital signs and to bridge the time to the start of the\nemergency operation [ 5].\nVentral hernia mesh repair may reduce tension on the\nabdominal wall, resulting in less recurrence compared\nwith a simple suture repair. Various complications\nassociated with hernia repair have been reported [ 2, 3].\nHowever, there are few reports in the literature regarding\nTP as a complication related to hernia repair. In our case,\nabdominal free air was noted on POD14 after ambulation.\nThe most plausible cause of TP was that air may have\nentered our patient ’s abdominal cavity via the unhealed\nabdominal wound, while the one-way valve effect devel-\noped due to morbid obesity. When reviewing the series of\nCT scans done on POD16, we found that fluid had accu-\nmulated from the mesh extending to the superficial\nwound (Fig. 3a–d), indicating the formation of a tract that\nallowed air to enter her abdominal cavity. When our\npatient began to ambulate, the thick abdominal subcuta-\nneous fat and muscle detached from the mesh. This effect\nmay have caused the formation of a small tract extending\nFig. 2 a Chest X-ray demonstrating an elevated diaphragm and suspicious pneumoperitoneum. b Computed tomography scan, transverse view.\nMassive free air and minimal ascites were noted in the abdomen\nLin et al. Journal of Medical Case Reports  (2018) 12:73 Page 3 of 5\n\nfrom the superficial wound to the subcutaneous fat and\nmesh and into her abdominal cavity. When she exhaled,\nan upward movement of her diaphragm created negative\npressure and caused a small amount of gas to enter her\nabdominal cavity. When she inhaled, although the down-\nward movement of her diaphragm created a relative posi-\ntive intra-abdominal pressure, her bowel may have sealed\nthe tract, resulting in the prevention of free air escaping\nfrom her abdominal cavity. When she was lying down, the\nsubcutaneous fat and muscle re-attached to the mesh, pre-\nventing the free air from leaving her abdominal cavity.\nDue to the valve effect, air accumulated gradually over\nseveral days and finally developed into TP.\nUnlike the TP caused by gastrointestinal perforation, it\nwas unnecessary for our patient to receive emergency\nlaparotomy to repair the perforation. The drainage of\nintra-abdominal free air is sufficient to improve this con-\ndition. As the abdominal wound healed, the gas route\nsealed gradually.\nConclusions\nMost surgery-related cases of pneumoperitoneum re-\nsolve spontaneously within 2 weeks after surgery. Cau-\ntion should be taken if the pneumoperitoneum occurs\nor progresses 2 weeks after surgery in an obese patient\nwith a mesh-repaired hernia. If accompanied by dys-\npnea, abdominal distention, and hemodynamic change,\nthe possibility of TP should be considered, and emergency\ndrainage of the intra-abdominal gas is needed. Emergency\nlaparotomy is unnecessary for this condition.\nAbbreviations\nBMI: Body mass index; CT: Computed tomography; POD: Postoperative day;\nTP: Tension pneumoperitoneum\nAcknowledgements\nNone.\nFunding\nNone.\nAvailability of data and materials\nRelevant data and supporting materials will be made available on request.\nAuthors’ contributions\nBSL, YSS, PYW, and KFH participated in patient care. WCL analyzed the X-ray\ndata. BSL and YSS wrote the manuscript. CHW and KFH revised and edited\nthe manuscript. All authors have read and approved the final manuscript.\nEthics approval and consent to participate\nWe have obtained a signed consent form from our patient that will be filed\nas part of our records.\nFig. 3 Computed tomography scan, contrast-enhanced transverse view, cranial ( a) to caudal ( d). Series of subcutaneous fluid accumulation ( yellow\narrows) extending from the mesh (between blue arrows) to the superficial incision wound\nLin et al. Journal of Medical Case Reports  (2018) 12:73 Page 4 of 5\n\nConsent for publication\nWritten informed consent was obtained from the patient for publication of\nthis case report and any accompanying images. A copy of the written\nconsent is available for review by the Editor-in-Chief of this journal.\nCompeting interests\nThe authors declare that they have no competing interests.\nPublisher’sN o t e\nSpringer Nature remains neutral with regard to jurisdictional claims in\npublished maps and institutional affiliations.\nAuthor details\n1Department of Family Medicine, National Cheng Kung University Hospital,\nCollege of Medicine, National Cheng Kung University, Tainan, Taiwan.\n2Department of Surgery, National Cheng Kung University Hospital, College of\nMedicine, National Cheng Kung University, Tainan, Taiwan. 3Department of\nRadiology, National Cheng Kung University Hospital, College of Medicine,\nNational Cheng Kung University, Tainan, Taiwan. 4Department of Obstetrics\nand Gynecology, National Cheng Kung University Hospital, College of\nMedicine, National Cheng Kung University, 138 Sheng Li Road, Tainan 704,\nTaiwan.\nReceived: 30 June 2017 Accepted: 24 January 2018\nReferences\n1. Reeves KW, Carter GC, Rodabough RJ, Lane D, McNeeley SG, Stefanick ML,\nPaskett ED. Obesity in relation to endometrial cancer risk and disease\ncharacteristics in the Women's Health Initiative. Gynecol Oncol.\n2011;121(2):376–82.\n2. Fischer JP, Wink JD, Nelson JA, Kovach SJ 3rd. Among 1,706 cases of\nabdominal wall reconstruction, what factors influence the occurrence of\nmajor operative complications? Surgery. 2014;155(2):311 –9.\n3. Regner JL, Mrdutt MM, Munoz-Maldonado Y. Tailoring surgical approach for\nelective ventral hernia repair based on obesity and National Surgical Quality\nImprovement Program outcomes. Am J Surg. 2015;210(6):1024 –9.\n4. Chan SY, Kirsch CM, Jensen WA, Sherck J. Tension pneumoperitoneum.\nWest J Med. 1996;165(1 –2):61–4.\n5. Symeonidis N, Ballas K, Pavlidis E, Psarras K, Pavlidis T, Sakantamis A.\nTension pneumoperitoneum: a rare complication of upper gastrointestinal\nendoscopy. JSLS. 2012;16(3):495 –7.\n6. Chiapponi C, Stocker U, Körner M, Ladurner R. Emergency\npercutaneous needle decompression for tension pneumoperitoneum.\nBMC Gastroenterol. 2011;11:48.\n•  We accept pre-submission inquiries \n  Our selector tool helps you to find the most relevant journal\n  We provide round the clock customer support \n  Convenient online submission\n  Thorough peer review\n  Inclusion in PubMed and all major indexing services \n  Maximum visibility for your research\nSubmit your manuscript at\nwww.biomedcentral.com/submit\nSubmit your next manuscript to BioMed Central \nand we will help you at every step:\nLin et al. Journal of Medical Case Reports  (2018) 12:73 Page 5 of 5","source_license":"CC0","license_restricted":false}