Perioperative Management of a Patient With Severe Bullous Emphysema

Patients with severe emphysematous bullae present significant anesthetic challenges, especially during laparoscopic or robotic-assisted surgeries, where positive pressure ventilation and pneumoperitoneum increase the risk of barotrauma. Rupture of a bulla can cause life-threatening tension pneumothorax, and intervention may be delayed in robotic cases due to limited access. A 62-year-old male patient with chronic obstructive pulmonary disease (COPD) and extensive bilateral bullous disease was scheduled for robotic-assisted laparoscopic inguinal hernia repair. Preoperative imaging revealed near-complete replacement of the upper right lung by giant bullae and substantial left-sided involvement. After a multidisciplinary discussion, the robotic approach was deemed unsafe due to the risk of bulla rupture during insufflation and positive pressure ventilation. Surgery was converted to an open repair under spinal anesthesia, with monitored anesthesia care using a propofol infusion. The patient remained hemodynamically stable, required no intraoperative airway intervention, and recovered without complication. This case highlights critical perioperative considerations in patients with bullous disease, including the limitations of chest tubes in decompressing a ruptured bulla with large bronchial communication, and the importance of individualized risk assessment beyond standard scoring systems. Preoperative imaging, multidisciplinary planning, and consideration of regional anesthesia can mitigate catastrophic complications. While alternative approaches such as regional blocks may offer a safer alternative for these patients, lung-protective ventilation strategies and avoidance of nitrous oxide are well-described for cases requiring general anesthesia. Patients with severe bullous emphysema require tailored perioperative planning. Early recognition, surgical approach modification, and the use of regional anesthesia can prevent life-threatening complications in high-risk non-thoracic surgeries.