What are the management options for a patient with a small pneumothorax (collapsed lung) during a Nissen fundoplication (surgical procedure for gastroesophageal reflux disease)?

Management of Small Pneumothorax During Nissen Fundoplication

For a small pneumothorax discovered intraoperatively during Nissen fundoplication, apply positive end-expiratory pressure (PEEP) immediately and continue the procedure laparoscopically if the patient remains hemodynamically stable; convert to open surgery only if hemodynamic instability develops despite PEEP. 1

Intraoperative Recognition and Diagnosis

Early detection is critical and relies on simultaneous monitoring of multiple parameters:

• Monitor for sudden increases in peak inspiratory pressure, decreased dynamic lung-thorax compliance, and rising end-tidal CO2 (PETCO2), which are the earliest indicators of pneumothorax during laparoscopic fundoplication 1
• Watch for decreased breath sounds on the affected side (typically left), wheezing, and decreased oxygen saturation, though SpO2 often remains normal initially 2, 1
• Pneumothorax occurs commonly during laparoscopic fundoplication (documented in 15% of cases in one series) because the left parietal pleura is directly exposed during dissection in the diaphragmatic hiatus and can be torn 1
• The pathophysiology differs from spontaneous pneumothorax: CO2 under pressure in the abdominal cavity passes directly into the pleural space, causing rapid accumulation 1

Immediate Intraoperative Management

The application of PEEP provides an effective alternative to chest tube placement for iatrogenic pneumothorax during laparoscopy:

• Apply PEEP immediately upon diagnosis, which largely corrects the respiratory changes (decreased compliance, increased airway pressures, increased CO2 absorption) without requiring chest tube placement 1
• Continue the laparoscopic procedure if the patient remains hemodynamically stable with PEEP, as none of the pneumothoraces treated with PEEP in the largest series required drainage 1
• Consider decreasing insufflation pressure and repositioning the patient to prevent further air entry into the pleural space 3

Convert to open surgery immediately if:

• Hemodynamic instability develops despite PEEP application (documented in 3 of 5 conversions in one series) 4
• Progressive deterioration in oxygenation or ventilation occurs 2
• The surgeon cannot safely continue dissection due to poor visualization or ongoing air leak 4

Postoperative Management

After completing the procedure (whether laparoscopically or open), management depends on pneumothorax size and patient stability:

• Obtain immediate postoperative chest radiograph to quantify pneumothorax size, as intraoperative assessment is unreliable 2
• For small iatrogenic pneumothorax (<2 cm rim) in a stable patient, observation with high-flow oxygen (10 L/min) is appropriate, as this increases reabsorption rate four-fold 5, 6
• Place a chest tube (small-bore catheter ≤14F or moderate-sized 16F-22F) if the pneumothorax is large (≥2 cm rim), the patient is symptomatic, or there is clinical instability 7
• Attach chest tubes to either a Heimlich valve or water seal device; apply suction only if the lung fails to reexpand with water seal alone 7

All patients with iatrogenic pneumothorax require hospitalization and close monitoring:

• Transfer to ICU for continuous monitoring if hemodynamic instability occurred intraoperatively or if the pneumothorax is large 3
• Monitor respiratory rate, heart rate, blood pressure, and oxygen saturation using the stability criteria: respiratory rate <24 breaths/min, heart rate 60-120 beats/min, normal BP, room air O2 saturation >90% 7
• Obtain serial chest radiographs to document resolution before discharge 2

Critical Pitfalls to Avoid

Do not delay recognition: The combination of increased peak inspiratory pressure, decreased compliance, and rising PETCO2 is diagnostic—do not wait for oxygen desaturation, which may occur late 1

Do not immediately place a chest tube intraoperatively: PEEP effectively treats most iatrogenic pneumothoraces during laparoscopy by preventing further CO2 entry and promoting lung re-expansion, avoiding the morbidity of intraoperative chest tube placement 1

Do not continue laparoscopy if hemodynamic instability develops: Three patients in one series required conversion specifically for hemodynamic instability from presumed pneumothorax, and all recovered after conversion to open surgery 4

Do not discharge patients on the same day: Even small iatrogenic pneumothoraces require observation, as they behave differently from spontaneous pneumothoraces due to the CO2 insufflation mechanism 1