Abstract
A 62-year old man was referred to our institution in hemorrhagic shock after a laparoscopic cholecystectomy for acute cholecystitis, performed at an outside hospital. A chest X-ray revealed a right-sided massive pleural effusion. Urgent surgical exploration was performed through a video-assisted mini-thoracotomy which revealed active bleeding from a pleural adherence. Successful hemostasis was achieved intraoperatively and the patient had an uneventful recovery. In absence of intra-abdominal hemorrhage, a hemothorax should be considered as a potential source of major bleeding in patients who develop symptoms of hypovolemia after laparoscopic surgery.
Highlights
Laparoscopic cholecistectomy (LC) is a wellestablished surgical procedure, a high index of suspicion should be maintained towards both surgical and anaesthetic complications [1]
Case presentation A 62-yrs old male patient was referred to our Institution due to massive right pleural effusion with severe hypovolemia at the end of VLC
At the end of procedure, before evacuation of pneumoperitoneum, the patient developed a hypotension which was initially responsive to fluid administration, but quickly deteriorated after the weaning resulting in severe hypovolemic shock with worsening of respiratory parameters
Summary
Laparoscopic cholecistectomy (LC) is a wellestablished surgical procedure, a high index of suspicion should be maintained towards both surgical (injury during blind trocar insertion, unrecognized diaphragmatic lesions) and anaesthetic complications (gas embolism, extraperitoneal insufflation and surgical emphysema, pneumothorax and pneumomediastinum) [1]. Case presentation A 62-yrs old male patient was referred to our Institution due to massive right pleural effusion with severe hypovolemia at the end of VLC. At the end of procedure, before evacuation of pneumoperitoneum, the patient developed a hypotension which was initially responsive to fluid administration, but quickly deteriorated after the weaning resulting in severe hypovolemic shock with worsening of respiratory parameters (tidal volumes, peak pressures and blood gases). A chest X-ray performed in the operating theatre revealed a white right hemithorax, suggestive for massive peri-operative pleural effusion, that was soon confirmed by a contrast enhanced chest CT-scan (Figure 1A-B). A total amount of 2400 of fluid and clotted blood was evacuated from pleural cavity, and active bleeding became evident from a vascularized adherence between parietal pleural and right diaphragm located nearby anterior costophrenic. Chest drainage tubes were removed on 3rd and 6th post-operative day, respectively
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