The most common causes of extraperitoneal insufﬂation are preperitoneal placement of the insufﬂating needle and leakage of CO2 around the cannula sites. Although this condition is usually mild and limited to the abdominal wall, subcutaneous emphysema can become extensive, involving the extremities, the neck, and the mediastinum. Another relatively common site for emphysema is the omentum or mesentery, a circumstance that may be mistaken for preperitoneal insufﬂation.
Subcutaneous emphysema may be identified by the palpation of crepitus, usually in the abdominal wall. Emphysema can extend along contiguous fascial plains to the neck, where it can be visualized directly. This finding may reﬂect mediastinal emphysema, which may indicate impending cardiovascular collapse (107–110).
The risk of subcutaneous emphysema is reduced by the proper positioning of the insufﬂation needle and by maintaining a low intraperitoneal pressure after placement of the desired cannulas. Other approaches that reduce the chance of subcutaneous emphysema include open laparoscopy and the use of abdominal wall lifting systems that make gas unnecessary.
If the insufﬂation occurred extraperitoneally, the laparoscope can be removed and the procedure can be repeated. Difficulty may ensue because of the altered anterior peritoneum. Open laparoscopy or the use of an alternate site, such as the left upper quadrant, should be considered. One approach is to leave the laparoscope in the expanded preperitoneal space while the insufﬂation needle is reinserted under direct vision through the peritoneal membrane caudad to the tip of the laparoscope (111).
In mild cases of subcutaneous emphysema, the findings quickly resolve after evacuation of the pneumoperitoneum, and no specific intraoperative or postoperative therapy is required.
When the extravasation extends to the neck, it is usually preferable to terminate the procedure because pneumomediastinum, pneumothorax, hypercarbia, and cardiovascular collapse may result. Following termination of the procedure, it is prudent to obtain a chest x-ray. The patient’s condition should be managed expectantly unless a tension pneumothorax results, in which case immediate evacuation must be performed using a chest tube or a wide-bore needle (14 to 16 gauge) inserted in the second intercostal space in the midclavicular line.
Complications of electrosurgery occur secondary to thermal injury from unintended or inappropriate use of the active electrode, current diversion to an undesirable path, or injury at the site of the dispersive electrode. Such complications may occur with the use of these instruments during laparoscopic, abdominal, or vaginal surgery. Active electrode injury can occur with either unipolar or bipolar instruments, whereas trauma secondary to current diversion and dispersive electrode accidents occurs only with unipolar devices. Complications of electrosurgery are reduced by adherence to safety protocols coupled with a sound understanding of the principles of electrosurgery and the circumstances that can lead to injury (112).
If the foot pedal is accidentally depressed, tissue adjacent to the electrode will be traumatized. Potential sites of injury include the bowel, ureter, and other intraperitoneal structures, or, if the electrode lies on the abdomen, the skin. Injury from direct extension of thermal effect can occur when the zone of vaporization or coagulation extends to large blood vessels or vital structures such as the bladder, ureter, or bowel. Bipolar instruments may reduce but do not eliminate the risk of thermal injury to adjacent tissue (113). Blood vessels should be isolated before electrosurgical coagulation, especially when they are near vital structures, and appropriate amounts of energy must be applied to allow an adequate margin of noncoagulated tissue.