Orbital emphysema post laparoscopic Nissen fundoplication in an adult with ventriculoperitoneal shunt. Case report

INTRODUCTION: Currently there is controversy with regard to safety of laparoscopic surgery performed in patients with a ventriculoperitoneal shunt (VPS). An increased intra-abdominal pressure and eventually impaired shunt function may possibly increase intracranial pressure. Although no report of pneumocephalus due to retrograde valve failure has been published, other complications may not be neglected. PRESENTATION OF CASE: A 72-year-old woman was scheduled for a laparoscopic Nissen fundoplication due to a large intrathoracic gastric hernia. Her medical history revealed a gait disorder, requiring a VPS for normotensive hydrocephalus, set up in the right lateral ventricle 11 years earlier. No neurological symptoms were revealed preoperatively. Surgery was uneventful. Postoperatively, important right palpebral emphysema was noticed. Her Glasgow score was 15. She presented no headache, no impairment of the visual acuity, with normal sensitivity and motricity. After multidisciplinary discussion, a chest and neck x-ray were performed. No other complications were noticed. The palpebral emphysema completely disappeared 3 days later. The patient was discharged uneventfully at day 5. DISCUSSION: Orbital emphysema is an uncommon clinical occurrence of subcutaneous emphysema. It may lead to compressive orbital emphysema when air enters the orbit but cannot leave it freely. The increase of intra-orbital pressure followed by intrabulbar hypertension may cause an occlusion of central retinal artery and optic nerve ischaemia. Tension pneumocephalus must concomitantly be excluded. CONCLUSION: Although orbital emphysema is often a benign finding, it may result in serious and life threatening complications that must be excluded in patients with a VPS.