How to manage a patient who underwent medical termination of pregnancy (MTP) with tubal ligation and presents with chest pain and pneumoperitoneum on day 2, but no peritoneal signs?

Management of Post-Laparoscopic Pneumoperitoneum Without Peritoneal Signs

In this hemodynamically stable patient with pneumoperitoneum but no peritoneal signs after MTP with tubal ligation, continue conservative non-operative management with close clinical monitoring, as the free air is most likely iatrogenic from the recent laparoscopic procedure rather than visceral perforation. 1

Clinical Context and Rationale

This presentation represents a common post-laparoscopic scenario where pneumoperitoneum persists for several days after surgery:

• Iatrogenic pneumoperitoneum from laparoscopy can persist for up to 3-7 days postoperatively and does not require surgical intervention 1
• The absence of peritoneal signs (no rigidity, no guarding, stable abdominal girth) strongly suggests non-surgical pneumoperitoneum 1, 2
• Surgical evaluation has already excluded acute peritonitis, which is the critical determinant for operative intervention 3, 1

Management Algorithm

Immediate Assessment (Already Completed)

• ✓ Hemodynamic stability confirmed
• ✓ Absence of peritoneal signs documented (no rigidity, no guarding)
• ✓ Stable abdominal girth
• ✓ Surgical evaluation performed

Conservative Management Protocol

Continue close clinical monitoring with:

• Serial abdominal examinations every 4-6 hours to detect any development of peritoneal signs 1, 4
• Monitor vital signs for hemodynamic instability or fever suggesting infection 1
• Laboratory surveillance including white blood cell count and inflammatory markers (CRP) 1
• Maintain nil per os status until chest pain resolves and clinical improvement is evident 3
• Broad-spectrum antibiotics should be continued for 3-5 days post-procedure as prophylaxis 3

Indications for Surgical Intervention

Immediate laparotomy is required ONLY if any of the following develop:

• Development of peritoneal signs (rigidity, guarding, rebound tenderness) 3, 1
• Hemodynamic instability or sepsis 3, 1
• Increasing abdominal distension or worsening pain 1, 4
• Rising inflammatory markers with clinical deterioration 1

Why Conservative Management is Appropriate

Non-operative management reduces morbidity and mortality in patients without active bleeding or bowel perforation 3, 5. The evidence strongly supports this approach:

• In hemodynamically stable patients with pneumoperitoneum but no clinical signs of peritonitis, conservative management is the standard of care 1, 2
• Non-therapeutic laparotomy carries significant risks including wound infection, eventration, and bowel obstruction in 10-40% of cases 3
• Delayed surgical intervention is only harmful when actual visceral perforation exists (fourfold mortality increase after 24 hours) 3, 5, but this patient has no evidence of perforation

Critical Pitfalls to Avoid

Do not operate based on radiographic pneumoperitoneum alone without clinical signs of peritonitis 1, 2. Key considerations:

• Free air on imaging is NOT specific for bowel perforation in the post-laparoscopic setting 1, 6
• The "board-like abdomen" may be absent even with true perforation in certain populations, but this patient has no peritoneal signs whatsoever 7
• CT scan is not indicated at this point since the patient is stable and surgical evaluation is complete 1

Expected Clinical Course

• Chest pain should resolve within 24-48 hours as residual CO2 is reabsorbed 1
• Pneumoperitoneum will gradually resolve over 3-7 days 1
• Patient can resume oral intake once pain improves and bowel function returns 3

If clinical deterioration occurs at any point, immediate surgical re-exploration is mandatory as delayed intervention for true perforation significantly increases mortality 3, 5.