Pneumomediastinum and ECG changes during laparoscopic Nissen fundoplication in a child; Case report

INTRODUCTION: Laparoscopic surgeries are becoming more popular in many surgical procedures particularly in pediatric age group. The physical responses and hemodynamic changes that occur during laparoscopic surgery differ between adults and pediatrics. CASE PRESENTATION: We report a sudden hemodynamic instability and abrupt ECG changes associated with pneumomediastinum (PM) during laparoscopic Nissen fundoplication surgery in a 19 months old boy who had gastro-esophageal reflux disease. Procedure was converted to open surgery and all parameters were spontaneously returned back to normal values. The patient was successfully extubated then transferred to intensive care unit (ICU) for close monitoring. He had uneventful post-operative course where PM has been completely resolved in the repeated chest x-ray. DISCUSSION: Pneumomediastinum (PM) occurs when air escape into the mediastinum. This air might reach the pericardium causing hemodynamic and electrophysiological changes. It is one of the reported complications that might occur during laparoscopic surgery, however isolated PM usually resolve spontaneously without any intervention. Etiology and possible contributing factors were discussed. CONCLUSION: Pneumoperitonium leads to different hemodynamic changes during laparoscopic surgery in pediatric population compared to adults. Decreasing the insufflation pressure and patient’s re-positioning might make continuing laparoscopy safe. However, surgeon must be willing to convert to open surgery to prevent any further complications.