AB208. SOH26AB_0268. Diffuse subcutaneous emphysema during laparoscopic totally extraperitoneal (TEP) inguinal hernia repair: a case report

Background: Diffuse subcutaneous emphysema is an uncommon but recognised complication of laparoscopic inguinal hernia repair, particularly in the totally extraperitoneal (TEP) approach. Although often benign, extensive emphysema can mimic more serious pathology and cause intraoperative concern.

Case Description: An 85-year-old male patient underwent emergency laparoscopic total extraperitoneal repair for a recurrent inguinal hernia. He has multiple presentations with incarceration of the inguinal hernia. He had an open left inguinal hernia repair done twice over the course of 25 years. He has a history of atrial fibrillation and liver cirrhosis. During dissection and insufflation, rapidly spreading subcutaneous emphysema developed involving the abdominal wall, chest, neck, and face. End-tidal carbon dioxide increased. Concern raised by anaesthesia to expedite the surgery. No visceral injury or pneumothorax was identified. The operation was completed laparoscopically, and the emphysema resolved spontaneously within 4 hours after surgery. Diffuse emphysema in TEP repair is usually associated with peritoneal tears, excessive insufflation pressure, or prolonged operative time. In this case, no tear was visualised, suggesting gas tracking along natural fascial planes. Management includes maintaining normocapnia, lowering insufflation pressure, monitoring airway pressures, and excluding life-threatening complications such as tension pneumothorax.

Conclusions: Diffuse subcutaneous emphysema during TEP repair, though alarming, is often self-limiting and manageable with appropriate intraoperative monitoring. Awareness of atypical gas-related complications enables safe completion of surgery and avoids unnecessary conversion or investigation.

Keywords: Recurrent hernia; totally extraperitoneal (TEP); surgical emphysema; inguinal hernia; case report