How to manage a patient with pneumoperitoneum on chest X-ray after VATS (Video-Assisted Thoracic Surgery) decortication with primary diaphragmatic repair?

Management of Post-VATS Pneumoperitoneum After Diaphragmatic Repair

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

Initial Clinical Assessment

Perform serial abdominal examinations every 4-6 hours for the first 48 hours post-operatively to detect evolving peritonitis, which would indicate a true surgical emergency requiring intervention. 1 The key distinction is between expected post-surgical pneumoperitoneum (which occurs in approximately 10% of cases without visceral perforation) and pathologic pneumoperitoneum from bowel injury. 2

Critical Clinical Indicators to Monitor

• Absence of peritoneal signs (rebound tenderness, guarding, rigidity) strongly supports conservative management 2, 3
• Serial laboratory monitoring including white blood cell counts and lactate levels every 12 hours for the first 48 hours to detect rising trends suggesting intra-abdominal pathology 1
• Hemodynamic stability with normal vital signs and absence of fever 3

Conservative Management Protocol

Thoracic Management

• Continue chest tube drainage on water seal or low suction (-20 cm H2O) to evacuate residual air and fluid from the thoracic cavity 1
• Monitor for air leak through the chest tube system, as persistent air leak beyond 5-7 days may require consideration of intrapleural sealants or surgical revision 1

Antibiotic Coverage

• Prophylactic antibiotics covering skin flora (cefazolin 1-2g IV every 8 hours) should be continued for 24-48 hours post-operatively 1
• If pleural space infection develops, escalate to vancomycin 15-20 mg/kg IV every 8-12 hours PLUS piperacillin-tazobactam 4.5g IV every 6 hours 1

Indications for Surgical Re-exploration

Proceed to urgent laparotomy only if the following develop:

• Clinical peritonitis with rebound tenderness, guarding, or rigidity on serial examinations 2, 3
• Sepsis without identified thoracic source characterized by fever, leukocytosis, and rising lactate without pleural space infection 1
• Hemodynamic instability not explained by thoracic complications 4
• Worsening abdominal distension with clinical deterioration 2

Common Pitfalls to Avoid

Do not reflexively operate based on radiographic pneumoperitoneum alone. In the literature, 61 of 139 reported cases of pneumoperitoneum underwent unnecessary surgical exploration without evidence of perforated viscus. 2 Conservative management is successful when peritonitis is absent, even with persistent radiographic findings. 3

Obtain pleural fluid analysis before assuming an abdominal source for symptoms such as fever, tachycardia, or leukocytosis, as empyema can mimic intra-abdominal sepsis. 1

Recognize that pneumoperitoneum can result from thoracic air leak through diaphragmatic apertures (foramen of Winslow) rather than visceral perforation, particularly after diaphragmatic manipulation during surgery. 2, 5

Expected Clinical Course

Pneumoperitoneum typically resolves spontaneously within 7-14 days with conservative management in the absence of true perforation. 2 Serial chest and abdominal radiographs can document resolution but should not drive management decisions in clinically stable patients. 3

If the patient remains clinically stable with benign abdominal examination and normal laboratory trends after 48-72 hours of observation, continue conservative management and advance diet as tolerated. 1, 3