title: Thoracic complications during urological laparoscopy.
abstract: OBJECTIVE
  We documented thoracic related complications during urological laparoscopic surgery.
  
  
  METHODS
  A total of 1129 patients underwent major urological laparoscopic procedures in a 5-year period. Operative reports and postoperative radiographic reports were retrospectively reviewed to identify patients with thoracic related medical and surgical sequelae. Of the patients 619 (55%) underwent at least 1 chest x-ray in the immediate or early postoperative period. In the remaining 510 patients (45%) there was no clinical indication to perform chest x-ray.
  
  
  RESULTS
  Of 619 patients undergoing chest x-ray 438 (71%) were completely normal. Medical pulmonary complications, surgical thoracic complications and subclinical, incidentally detected gas collections in the chest were identified in 12.6%, 0.5% and 5.5% of patients, respectively. Medical complications in 12.6% of cases included pulmonary infiltrate/atelectasis in 9.7%, pleural effusion in 4.8% and pulmonary embolus in 0.3%. Surgical complications included symptomatic pneumothorax in 4 patients (0.35%), hemothorax in 1 (0.08%) and chylothorax in 1 (0.08%). Subclinical abnormal thoracic gas collections were radiographically noted in 34 of the 619 patients (5.5%) on chest x-ray, including pneumomediastinum in 19 (3.1%), pneumothorax in 10 (1.6%) and pneumopericardium in 5 (0.8%). Overall 36 of 40 (90%) thoracic surgical complications (3) and subclinical, incidentally detected gas collections (33) occurred during retroperitoneal laparoscopy. Re-intervention was necessary in 6 patients (0.5%), namely pulmonary embolus requiring vena caval filter placement in 3 (0.3%), pneumothorax requiring a chest tube in 2 (0.17%) and hemothorax requiring emergency open thoracotomy in 1 (0.08%). No patient underwent open conversion to complete the initial proposed operation.
  
  
  CONCLUSIONS
  Due to its high solubility the expectant management of incidental CO2 pneumothorax, pneumopericardium and pneumomediastinum is recommended initially in the clinically stable patient. Inadvertent diaphragmatic entry can be satisfactorily repaired laparoscopically without open conversion. Although it is rare, surgical thoracic complications are potentially life threatening, requiring prompt identification and management.
authors.affiliation: Section of Laparoscopic and Minimally Invasive Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
authors.forename: Sidney C
authors.initials: SC
authors.lastname: Abreu
authors.forename: David S
authors.initials: DS
authors.lastname: Sharp
authors.forename: Anup P
authors.initials: AP
authors.lastname: Ramani
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Steinberg
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Ng
authors.forename: Mihir M
authors.initials: MM
authors.lastname: Desai
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000453:epidemiology; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011030:Pneumothorax / Q000453:epidemiology / Q000209:etiology; D012189:Retrospective Studies; D013520:Urologic Surgical Procedures / Q000009:adverse effects*