Spontaneous pneumothorax during vaginal hysterectomy in lithotomy with steep Trendelenburg position—a case report

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Abstract

Background

Pneumothorax associated with a steep head-down position in vaginal hysterectomy surgery is rare but can cause life-threatening complications.
Case presentation
We report a case of a female patient with no obvious lung pathology who suffered intraoperative pneumothorax associated with prolonged steep Trendelenburg position. To the best of our knowledge, this is the first well-documented case of this association. A 53-year-old female, diagnosed as a case of recurrent umbilical hernia with cystocele and rectocele was planned for vaginal hysterectomy with anterior perineorrhaphy and posterior colpoperineorrhaphy along with open mesh repair for umbilical hernia under general anaesthesia. Approximately 90 min after the steep Trendelenburg position, the peak inspiratory pressure increased, while the oxygen saturation decreased. The airway pressures remained continuously on the higher side whole throughout the surgery despite an interrupted propped-up position in between. The patient could not be extubated and shifted to the intensive care unit (ICU) where ultrasonography (USG) of the lung and chest x-ray showed signs of pneumothorax. Intercostal tube drainage (ICTD) was placed, and the patient improved dramatically. It was suspected that a steep head-down position for a prolonged period led to persistently raised airway pressures and the subsequent development of pneumothorax.
Conclusions
Pneumothorax can develop in rare circumstances even if airway pressures are under the safety range. So, careful monitoring and immediate treatment are necessary to prevent the condition from worsening and anaesthesiologists must be aware of such potential danger.

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