Laparoscopy is widely used for diagnostic as well as therapeutic purposes in gynaecology. The green top guidelines on the management of endometriosis produced by the Royal College of Obstetricians and Gynaecologists recommend advanced laparoscopic surgery for treatment of severe endometriosis. Here, we present three very unusual cases of hydrothorax developed as a complication of advanced laparoscopic surgery for endometriosis.
The first patient was a 38-year-old nulliparous woman with BMI of 25.7 with known severe endometriosis referred to gynaecology clinic for consideration of advanced laparoscopic surgery. The patient had undergone diagnostic laparoscopy with no complications in the past. She was fit with no significant past medical history. Preoperative investigations were unremarkable.
The patient was intubated, paralysed and ventilated during the operation. She was in lithotomy position with modest Trendlenburg tilt. An average intraperitoneal pressure of 15 mmHg was maintained during the procedure.
Introperatively, she was found to have stage IV endometriosis with dense adhesions involving both tubes and ovaries. Laparoscopic adhesiolysis and laser treatment of endometriosis was carried out. The procedure lasted for 1 hour. A total of 3 l of normal saline were used for suction irrigation. Although the exact irrigation balance was not recorded, it was assumed that the majority of the fluid was recovered. At the end of the procedure, 1.5 l of ADEPT (4% icodextrin) was left in the peritoneal cavity.
About 40–45 minutes into the operation, it became difficult to ventilate the patient. Her airway pressure increased, end tidal CO2 increased and oxygen saturation dropped from 100 to 90% on an FiO2 of 0.5. This occurred over a period of 5–10 minutes. Saturations improved to 96% on 100% oxygen. At this stage, almost 2500 ml of saline had been used for irrigation. On auscultation, breath sounds were present bilaterally. The operation was completed in the next 20 minutes. The patient required to be ventilated with 100% oxygen to maintain saturations over 90%. It was deemed unsafe to extubate the patient. Arterial blood gas analysis showed Po2 of 11.2 kPa and Pco2 of 7.8 kPa on 100% oxygen with 5 cm positive end-expiratory pressure (PEEP).
At this stage, breath sounds were noticed to be diminished over the right side of the chest. A portable chest X-ray showed a white out of the right side (Figure 1). An ultrasound scan was performed, which demonstrated the presence of a large amount of fluid in the right hemithorax. A chest drain was inserted in the right pleural cavity and immediately, almost a litre of fluid was drained. Repeat arterial blood gas analysis showed Po2 of 43.2 kPa and Pco2 of 5.3 kPa.
The right lung did not inflate adequately and thus the patient was transferred to ITU. She was ventilated overnight and extubated the following morning and recovered rapidly. The patient was discharged home on the subsequent day from the ITU. Cytology and microbiology examination of the fluid was negative.
The patient was reviewed for follow-up visit in the gynaecology clinic 3 weeks postoperatively and was well.
The second patient was a 38-year-old nulliparous woman with the BMI of 24 and known Stage IV endometriosis. She had undergone laparoscopy and laser treatment of endometriosis 3 years ago without any complications. Normal saline was used for irrigation and 1 l of ADEPT was left in the peritoneal cavity at the end of the procedure. She then had two cycles of IVF with unsuccessful outcomes and was referred from the assisted conception unit for further laparoscopic surgery in view of worsening symptoms.
The patient was intubated, paralysed and ventilated for the operation and the average intraperitoneal pressure of 15 mmHg was maintained.
Intra-operatively, she was found to have stage IV endometriosis with adhesions involving left tube and ovary. Endometriosis was present on both uterosacral ligaments. The uterus was retroverted and fixed. Laparoscopic laser treatment and adhesiolysis was performed. The procedure lasted for 80 minutes. The exact amount of saline used for the procedure and the irrigation balance was not recorded. One and a half litres of ADEPT was left in the peritoneal cavity at the end of the procedure.
The patient was well intra-operatively with SpO2 of 98–100% and there were no problems in the recovery room. She started complaining of difficulty in breathing and right-sided shoulder-tip pain on the night of the operation. At 9 p.m. in the evening after the operation, her oxygen saturation dropped to 95% on air; her respiratory rate was 30/minute and pulse was 100 bpm. Chest X-ray demonstrated a left-sided basal effusion. Arterial blood gas analysis showed Pco2 of 5.4 kPa and Po2 of 12.4 kPa on 60% oxygen. Needle aspiration of the fluid was performed and sent for cytology and biochemistry. She was transferred to HDU for observation. Her SpO2 improved with oxygen. She recovered well and was discharged home on the third postoperative day.
The patient was reviewed in the gynaecology clinic 5 weeks after the operation and was well.
The third patient was a 44-year-old nulliparous woman with a long standing history of endometriosis. She had a BMI of 23.8. She had undergone laparoscopic laser treatment of endometriosis twice in the past 5 years. Both these times, the procedures had lasted for 20 and 40 minutes respectively. Unfortunately, there is no record of amount of fluid used for irrigation or the amount of ADEPT left in the peritoneal cavity at the end of these procedures.
The patient was intubated, paralysed and ventilated for the operation. She was found to have widespread endometriosis, which was treated with laser. Normal saline was used for suction irrigation (balance not recorded) and 1.5 l of ADEPT was left in the peritoneal cavity at the end of the procedure. The procedure lasted for 30 minutes.
The oxygen saturations were unchanged throughout the procedure and she was well in the immediate postoperative period. Her SpO2 dropped to 95% on the evening of the operation. By 6 a.m., the following morning, the SpO2 dropped to 93% on air and she was started on 2 l of oxygen. She started complaining of discomfort while breathing and right-sided shoulder-tip pain. A chest X-ray reported, ‘Right-sided pleural effusion extending into right mid zone along oblique fissure with right basal lung collapse’. The patient was transferred to respiratory ward. Repeat chest X-ray in 48 hours showed that the effusion had resolved spontaneously.
The patient was followed up in gynaecology clinic in 3 months and was well.