What is the management approach for a patient with pneumoperitoneum on post-operative chest X-ray after VATS (Video-Assisted Thoracic Surgery) decortication, deloculation with primary repair of diaphragmatic injury?

Management of Post-VATS Pneumoperitoneum After Diaphragmatic Repair

In a patient with pneumoperitoneum on chest X-ray following VATS decortication with primary diaphragmatic repair, conservative management with close clinical observation is the appropriate initial approach, as pneumoperitoneum is an expected finding after diaphragmatic manipulation and does not require surgical re-exploration in the absence of peritonitis. 1, 2

Initial Assessment and Clinical Monitoring

The critical distinction is between expected post-surgical pneumoperitoneum versus peritonitis requiring intervention:

• Assess for peritoneal signs: Examine specifically for abdominal rigidity, rebound tenderness, guarding, fever >38.5°C, and hemodynamic instability (tachycardia >110 bpm, hypotension) 3, 2
• Serial abdominal examinations: Perform focused abdominal exams every 4-6 hours for the first 48 hours post-operatively to detect any evolving peritonitis 4, 3
• Laboratory monitoring: Check serial white blood cell counts and lactate levels; rising trends suggest intra-abdominal pathology requiring intervention 4, 3

Pneumoperitoneum after diaphragmatic repair is commonly benign: Air can track through the surgical repair site or diaphragmatic apertures (foramen of Winslow) from the thoracic cavity, particularly after decortication procedures that involve extensive pleural manipulation 1, 2

Conservative Management Protocol

If the patient is clinically stable without peritoneal signs, proceed with observation:

• Continue chest tube drainage: Maintain existing chest tubes on water seal or low suction (-20 cm H2O) to evacuate residual air and fluid from the thoracic cavity 1, 4
• NPO status initially: Keep patient nil per os for 24-48 hours, then advance diet as tolerated if no peritoneal signs develop 3
• Serial imaging: Obtain daily upright chest X-rays to monitor for resolution of pneumoperitoneum and assess lung re-expansion 5, 6
• Antibiotic coverage: Continue prophylactic antibiotics covering skin flora (cefazolin 1-2g IV every 8 hours) for 24-48 hours post-operatively 4

Expected timeline: Pneumoperitoneum typically resolves spontaneously within 3-7 days as air is reabsorbed and the diaphragmatic repair seals 3, 2

Indications for Surgical Re-exploration

Proceed to exploratory laparotomy only if clinical deterioration occurs:

• Development of peritonitis: New-onset abdominal rigidity, rebound tenderness, or guarding 3
• Hemodynamic instability: Persistent tachycardia, hypotension, or rising vasopressor requirements not explained by thoracic pathology 5
• Increasing pneumoperitoneum: Progressive free air on serial imaging with clinical deterioration suggests ongoing visceral perforation 3
• Sepsis without source: Fever, leukocytosis (WBC >15,000), and rising lactate without identified thoracic infection 4

Management of Thoracic Complications

Simultaneously monitor for post-VATS thoracic complications that may require intervention:

• Pleural space infection: If fever develops with purulent chest tube drainage, obtain pleural fluid culture and pH; initiate vancomycin 15-20 mg/kg IV every 8-12 hours PLUS piperacillin-tazobactam 4.5g IV every 6 hours 4
• Persistent air leak: If air leak continues beyond 5-7 days, consider intrapleural sealants or surgical revision 1, 6
• Retained hemothorax: If chest tube output decreases but imaging shows residual fluid collection, consider intrapleural fibrinolytics (TPA 10mg plus DNase 5mg twice daily for 3 days) before repeat VATS 4, 7

Critical Pitfalls to Avoid

Do not perform exploratory laparotomy based solely on radiographic pneumoperitoneum: The presence of free air after diaphragmatic surgery is expected and does not mandate surgical exploration in asymptomatic patients 3, 2

Do not delay conversion to open thoracotomy if VATS visualization was inadequate: If the initial VATS procedure had poor visualization due to adhesions, there is a 20% risk of incomplete decortication requiring early reoperation 8

Do not attribute all symptoms to the pneumoperitoneum: Fever, tachycardia, or leukocytosis may indicate pleural space infection rather than intra-abdominal pathology; obtain pleural fluid analysis before assuming abdominal source 4, 7