嚴重皮下氣腫於全腹膜外腹腔鏡手術後之處置：病例報告及文獻回顧

黃君平、高建璋、曹智惟、楊明昕

國防醫學大學三軍總醫院外科部泌尿外科

Management of Severe Subcutaneous Emphysema After Totally Extraperitoneal Laparoscopic Surgery A Case Report and Literature Review

Chun-Ping Huang, Chien-Chang Kao, Chih-Wei Tsao, Ming-Hsin Yang

Division of Urology, Department of Surgery, Tri-Service General Hospital, National Defense Medical University, Taipei 114024, Taiwan

Introduction: Laparoscopic total extraperitoneal (TEP) herniorrhaphy is a common surgical approach for repairing inguinal hernias. While generally safe, the procedure involves gas insufflation which can lead to complications such as subcutaneous emphysema and pneumoperitoneum if gas migrates beyond the intended preperitoneal space. Although these issues are often self-limiting, they can occasionally progress to cause significant respiratory or abdominal distress requiring medical intervention

Case presentation: A 45-year-old male with a medical history of hyperlipidemia presented with a two-week history of palpable masses in the bilateral inguinal regions. Physical examination confirmed reducible masses, and he was diagnosed with bilateral inguinal hernias.

On October 9, 2025, the patient underwent bilateral laparoscopic TEP herniorrhaphy with mesh. Postoperatively, he developed subcutaneous emphysema of the neck, pneumoperitoneum, and a scrotal hematoma. He was initially managed with oral medications.

However, the patient returned to the emergency room the following day due to progressive abdominal bloating and dyspnea. Physical examination revealed a hard, ovoid abdomen with tenderness and hypoactive bowel sounds. Laboratory investigations showed elevated liver enzymes (AST 102 U/L, ALT 286 U/L) and a CRP of 1.12 mg/dL. A chest and abdominal CT scan revealed marked pneuoperitoneum, mild pneumomediastinum, and diffuse subcutaneous emphysema extending from the scrotal region to the chest wall.

Sono-guided drainage for pneumoperitoneum was performed and the procedure successfully relieved his symptoms, and his vital signs normalized. After further observation and management, the patient was discharged on October 19 in stable condition

Discussion: The primary complications in this case—massive pneumoperitoneum and extensive subcutaneous emphysema—resulted from the migration of insufflated gas during the TEP procedure. While the TEP technique is designed to stay outside the peritoneal cavity, gas can enter the peritoneum if the peritoneal membrane is inadvertently breached. CO2 gas follows paths of least resistance along fascial planes, which explains the progression from the scrotum to the neck and mediastinum.

In this case, the severity of the gas accumulation caused tension-like symptoms (dyspnea and severe bloating), which required needle puncture decompression to alleviate pressure. While imaging is essential to rule out organ perforation, percutaneous needle decompression is a critical, potentially life-saving technique for immediate pressure release in symptomatic patients. The CT scan did not show significant abnormalities in the liver or biliary system. The elevated liver enzymes suggest that may have been a transient response to the pressure that compresses hepatic vessels or the surgical procedure itself.

Conclusion: This case illustrates that complications from laparoscopic hernia repairs, such as pneumoperitoneum, can present with delayed or progressive symptoms after discharge. Prompt recognition and imaging (CT scans) are essential to differentiate between benign post-operative gas retention and life-threatening conditions like a perforated viscus. Needle decompression remains a vital and effective intervention for patients experiencing symptomatic tension from retained surgical gas.