P066: SUBCUTANEOUS EMPHYSEMA, PNEUMOMEDIASTINUM, AND ARRHYTHMIA: AN UNEXPECTED 48-HOUR POSTOPERATIVE CHALLENGE
Cameron Perrone, MS1; Milayna Kokoska, MS1; Jacob Abulencia, MS1; Michele Retrouvey, MD1; Paul Kolbert, MD2; George Luck, MD1
1Florida Atlantic University Charles E. Schmidt College of Medicine; 2Anesco North Broward
Introduction/Background: As minimally invasive robotic surgeries become more common, rare cases and unique complications are more likely to arise. Such is the case for an interesting complication seen in a patient who had undergone a robotic radical prostatectomy & right inguinal hernia repair.
48 hours after the procedure, the patient developed subcutaneous emphysema, pneumomediastinum, and atrial fibrillation. Subcutaneous emphysema only occurs in 2-4% of robotic and laparoscopic procedures in general, while pneumomediastinum is too rare to accurately quantify.
This combination of symptoms is seemingly unique among patients who have undergone this specific procedure, and exceedingly rare among patients who have undergone any type of robotic surgery. Delving into this unique case may provide insight into rare complications of robotic procedures, which could aid in identification and rapid management of said complications when they do arise.
Case Presentation: This case involves a 66-year-old male patient who underwent a radical prostatectomy and right inguinal hernia repair via robotic surgery. The surgery itself was uneventful, and the patient was subsequently admitted to the hospital for observation. Approximately 48 hours post-operatively, the patient developed subcutaneous emphysema extending from the thighs to the neck. Shortly thereafter, he developed atrial fibrillation with a rapid ventricular rate. Chest X-ray performed at that time demonstrated pneumomediastinum. The likely cause of these symptoms was iatrogenic insufflation that occurred during the robotic procedure. The patient’s symptoms were identified and managed appropriately in hospital without further complications.
Discussion: This case highlights the rare occurrence of subcutaneous emphysema, pneumomediastinum, and new-onset atrial fibrillation following a robotic-assisted radical prostatectomy and inguinal hernia repair.?
Subcutaneous emphysema originates from abdominal insufflation with carbon dioxide to establish pneumoperitoneum, creating high intra-abdominal pressures wherein gas dissects along fascial planes. While most cases are self-limiting in nature, severe cases can be exacerbated by risk factors such as BMI < 25 kg/m2, operating time over 200 minutes, age over 65 years, and significant time spent in Trendelenburg position, all of which were present in this patient. These risk factors allow for increased volumes of gas to slowly migrate throughout the body. In this instance of pneumomediastinum, entry of gas into the mediastinum was gradual, causing a delay in symptom onset.?
The patient's development of atrial fibrillation was likely induced by excessive catecholamine secretion elicited by the combined effects of hypercarbia, fluid overload, systemic inflammation, and pathological stress. There have also been instances of tension pneumomediastinum induced cardiac tamponade, leading to atrial fibrillation, introducing another possible route for complications. ?
As surgical techniques evolve, further research is needed to identify strategies for minimizing such risk factors. Improved understanding of patient selection, optimal intraoperative parameters, and early detection protocols may help reduce the incidence of similar complications. Thorough documentation of rare cases like this one is essential for guiding clinical practice and enhancing the safety of robotic surgical procedures.