Massive subcutaneous emphysema and hypercarbia

W hile the laparoscopic approach to surgery is not new, its application has expanded tremendously within the past decade. Initially used as early as 1937 for gynecological procedures, it now is also a preferred method of approach in many general, urologic, and thoracic procedures. Examples of these procedures include tubal ligation, chromopertubation study, cholecystectomy, esophageal fundoplication, splenectomy, pelvioscopy, and diagnostic thoracoscopy. In this article, the case studies involve the general surgery procedures of laparoscopic total extraperitoneal (TEP) inguinal herniorrhaphy and laparoscopic colectomy. In the TEP approach for herniorrhaphy, a small incision is made in the midline near the umbilicus. An extraperitoneal space is created using blunt dissection or balloon inflation to expand the space. Laparoscopic instruments then are inserted into the abdominal wall through infraumbilical and suprapubic incisions. This extraperitoneal space is expanded further with carbon dioxide (CO2) insufflation. Once the hernia is dissected, a polypropylene mesh graft is inserted and then secured by mechanical means (eg, staples, sutures, or adhesives) or by allowing the patient’s own anatomy, postexsufflation, to contract, holding the mesh in place. In a totally laparoscopic approach to colectomy, the initial incision is made at the umbilicus to allow the intraperitoneal insertion of the laparoscope and for The laparoscopic approach to surgery is being used with