Hemothorax as complication of laparoscopic technique

: A 69-year-old woman with a hiatal hernia and esophagitis caused by reflux was scheduled for laparoscopic Nissen fundoplication. Anesthetic induction was accomplished with fentanyl, propofol and rocuronium and maintenance with sevoflurane and rocoronium. Hemodynamics were stable until the end of surgery, when a sudden decrease in blood pressure to 40/20 mm Hg and arterial carbon dioxide tension to 14 mm Hg were observed. Anesthetic insufflation was stopped and physiological saline solution and ephedrine were administered. Hemothorax and air embolism were ruled out. After hemodynamic recovery, renewal of anesthetic insufflation was contraindicated, laparoscopy was halted, and hemoperitoneum was ruled out. After extubation, the patient was transferred to the recovery room, where hemodynamic instability worsened progressively. A chest radiograph suggest left hemothorax and an emergency thoracotomy was performed. After evacuation of multiple clots from the pleural cavity, the point of hemorrhage was located at the right crus of the diaphragm and bleeding was arrested. Postoperative recovery continued with no further events. The most common complications of laparoscopy are pneumothorax, gastroesophageal perforation and hemorrhage. However, given the complexity of the technique, the possibility of bleeding in the pleural cavity, as occurred in this case, should be considered. This case highlights the importance of rigorous intraoperative monitoring and postoperative surveillance by the anesthesiologist.