Huang R, Ragheb J
Cureus 17(8): e89700. doi:10.7759/cureus.89700
This case report describes the perioperative management of a 62-year-old male with severe bilateral bullous emphysema undergoing inguinal hernia repair. Preoperative imaging revealed giant bullae replacing most of the right upper and middle lobes and significant left apical disease. Given the high risk of bulla rupture during pneumoperitoneum and positive pressure ventilation—especially with limited access in robotic surgery—the planned robotic-assisted laparoscopic repair was converted to an open procedure under spinal anesthesia with monitored anesthesia care using propofol.
The patient remained stable throughout surgery, required no airway intervention, and recovered without complication. The report emphasizes that bullae rupture can occur from positive pressure ventilation, nitrous oxide diffusion, or forceful exhalation, and that chest tube drainage may be inadequate if the bulla communicates widely with the bronchus. Key management points include individualized risk assessment beyond standard scoring tools, review of preoperative imaging, multidisciplinary planning, and considering regional anesthesia to avoid positive pressure ventilation. If general anesthesia is necessary, lung-protective strategies, low inspiratory pressures, avoidance of nitrous oxide, and smooth intubation/extubation are recommended.
This case underscores that in patients with severe bullous disease, early recognition, surgical plan modification, and regional anesthesia can prevent life-threatening complications in non-thoracic surgery.
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