laparoscopic pyeloplasty ( lp ) is a minimally invasive alternative to open pyeloplasty for the treatment of ureteropelvic junction obstruction .
it has been shown to provide lower patient morbidity , shorter hospitalization and faster convalescence .
however , there is an inherent risk of surgical ( blind trocar insertion , colonic injury , hemorrhage , ileus , urinoma formation ) and anesthetic complications ( gas embolism , extraperitoneal insufflation and surgical emphysema , pneumothorax and pneumomediastinum ) .
an 18-year - old girl was diagnosed to have left pelviureteral junction obstruction during evaluation of left flank pain .
three trocars , including a 10 mm umbilical trocar , a 10 mm trocar midway between the umbilicus and the symphysis , and a 5 mm trocar midway between the umbilicus and xiphoid were used .
the entire procedure was completed in 90 minutes , and a drain was placed after confirming hemostasis . however , at the end of the procedure , before evacuation of pneumoperitoneum , the patient developed hypotension .
this was initially responsive to fluid administration , but quickly deteriorated after weaning , resulting in severe hypovolemic shock with worsening of respiratory parameters ( tidal volumes , peak pressures and blood gases ) .
a pneumothorax was suspected , and a needle was inserted into the left fifth intercostal space .
however , it drained blood and a chest x - ray revealed a hazy left hemithorax . screening ultrasound and contrast enhanced chest computed tomography ( ct )
scan showed a massive hemothorax with no hemoperitoneum ( ultrasound and ct installations are within the operation theatre complex ) .
a 28 french intercostal tube was inserted in the left fifth intercostal space , and 2 l of blood was drained .
the patient continued to remain hypotensive despite resuscitation and blood transfusion and more than 500 ml blood drained through the intercostal tube during the subsequent 2 h. an emergency surgical exploration was planned . in any case of hemothorax following an abdominal procedure , the first suspicion is towards an abdominal cause and a laparotomy was performed but it did not reveal any blood in the peritoneal cavity .
a subsequent left mini - thoracotomy revealed fresh and clotted blood in the pleural cavity , which was evacuated .
an active bleeding vessel became evident in the thoracic aspect of the left diaphragm near the anterior costophrenic angle secondary to a small diaphragmatic cautery burn .
hemostasis was achieved by under - running the bleeding vessel , and an intercostal drain was placed .
the post - operative course was uneventful , and complete lung re - expansion was achieved .
thoracic bleeding is a rare complication of elective abdominal surgery , mainly resulting from unrecognized , iatrogenic diaphragmatic tears .
cristian et al . , have reported a case of massive right hemothorax causing hemorrhagic shock after laparoscopic cholecystectomy .
the bleed was from a laceration of the parieto - diaphragmatic adherence , which was attributed to change in diaphragmatic position during pneumoperitoneum , as it has been demonstrated in animal models .
have reported severe hemothorax after laparoscopic surgery for endometriosis , which was attributed to pulsatile active bleeding from scattered small endometriotic lesions present on the pleural surface of the right diaphragm .
abreu et al . have reported that thoracic surgical complications occurred in only 0.5% of the patients .
of the 1,129 patients operated laparoscopically , only one patient demonstrated a hemothorax ( 0.08% ) , which was attributed to accidental supracostal placement of the posterior port .
most complications occur during creation of pneumoperitoneum and blind insertion of the first trocar , not because of the laparoscopic surgery . in this case
, the hemothorax was probably caused due to injury to the diaphragm by an unrecognized cautery burn , following which the bleeding vessel retracted into the thorax . the colon is routinely mobilized during lp .
the cautery burn probably occurred during the mobilization of the splenic flexure with the monopolar cautery .
hypotension due to blood loss was evident only after evacuation of the intra - abdominal gas and the natural suspicion was of an intra - abdominal source of bleeding . there needs to be a high index of suspicion of possible thoracic complications during laparoscopic urological procedures .
 laparoscopic pyeloplasty is viable standard minimally invasive alternative to open pyeloplasty for the treatment of ureteropelvic junction obstruction . 
 intrathoracic bleeding is an extremely rare complication after laparoscopic urological surgery , but it should be suspected and promptly diagnosed in case of worsening hemodynamic status and respiratory parameters during the intra or post - operative course . 
 we report a case of hemothorax complicating an otherwise uneventful lp in an 18-year - old girl . 
INTRODUCTION
CASE REPORT
DISCUSSION