Identification and Management of Intraoperative Pneumothorax During Laparoscopic Surgery: A Rare Complication.

Pneumothorax is a rare but potentially life-threatening intraoperative complication during general anesthesia, with early recognition often challenging due to nonspecific hemodynamic and respiratory changes that may mimic other anesthetic or surgical issues. The risk is increased in laparoscopic procedures due to pneumoperitoneum and possible diaphragmatic or pleural injury, as well as in the presence of preexisting pulmonary disease, elevated airway pressures, central venous catheterization, and airway manipulation during intubation. Although it is an uncommon complication in laparoscopic surgeries, delayed diagnosis can lead to hypoxia, hemodynamic instability, and fatal outcomes. We report a case of a 34-year-old female patient (ASA II) with superior mesenteric artery syndrome and a history of gastrojejunostomy who underwent emergency duodenojejunostomy with reversal of the gastrojejunostomy under general anesthesia. The patient was intubated successfully and ventilated using pressure-controlled ventilation; however, intraoperatively, airway pressures rose to 29 cmH₂O, and capnography showed a delayed upstroke, indicating possible airflow obstruction. She developed bilateral subcutaneous emphysema over the neck, oxygen desaturation to 85%, tachycardia (120 bpm), hypertension (mean arterial pressure 119 mmHg), and elevated end-tidal CO₂ (>55 mmHg). The surgery was immediately halted, endotracheal tube placement was confirmed, and manual ventilation with 100% oxygen improved oxygen saturation to above 93%. Reduced air entry over the right lung field raised suspicion of right-sided pneumothorax, which was confirmed via intraoperative chest radiography. An emergency intercostal chest tube was inserted, leading to rapid improvement in ventilation and oxygenation. The procedure was subsequently aborted, and the patient was transferred to the intensive care unit for monitoring. She recovered without complications, was discharged in stable condition, and remained asymptomatic on follow-up without recurrence. This case highlights the critical importance of vigilance, early recognition of warning signs, and prompt intervention to prevent severe complications.