Tension pneumothorax following laparoscopic Hartmann procedure reversal: a case report

Pneumothorax is an uncommon but potentially serious complication encountered during laparoscopic surgery. Its intraoperative manifestations may overlap with the expected respiratory effects of carbon dioxide pneumoperitoneum and general anesthesia, potentially complicating timely recognition. We report a case of right-sided tension pneumothorax identified shortly after laparoscopic Hartmann procedure reversal, with particular attention to the evolving perioperative respiratory findings and diagnostic sequence. A 56-year-old woman with a body mass index of 35.4 kg/m 2 and American Society of Anesthesiologists physical status II underwent elective laparoscopic Hartmann procedure reversal approximately 2 months after emergency laparoscopic sigmoidectomy with Hartmann colostomy for perforated sigmoid cancer. Preoperative chest radiography and pulmonary function testing were unremarkable. Approximately 1 hour after establishment of carbon dioxide pneumoperitoneum, decreased tidal volume, increased airway pressure, a rise in end-tidal carbon dioxide to 45 mmHg, oxygen desaturation to 86%, and mildly decreased right-sided breath sounds were observed. Pneumoperitoneum was temporarily released, with partial respiratory improvement, and the procedure was subsequently resumed. At the end of surgery, she was unable to maintain adequate spontaneous ventilation. In the recovery unit, the patient developed decreased consciousness and gasping respirations, with venous blood-gas analysis showing pH 7.10 and PCO₂ 72 mmHg. Following transfer to the intensive care unit and subsequent extubation, her respiratory condition deteriorated within minutes. Portable chest radiography demonstrated a right-sided tension pneumothorax with tracheal deviation. Emergency pleural decompression using a 14-F pigtail catheter resulted in clinical improvement and complete radiographic re-expansion of the right lung. Tension pneumothorax associated with laparoscopic surgeries should be considered when unexplained ventilatory abnormalities occur, even during lower gastrointestinal procedures and in the absence of recognized risk factors. Transient improvement after desufflation does not exclude pneumothorax and may delay recognition of evolving tension physiology. Early suspicion and prompt pleural decompression are essential to prevent life-threatening complications.