Abstract
BACKGROUND: During laparoscopic surgery, tension pneumothorax may persist despite prompt anatomical repair of a diaphragmatic injury, posing a diagnostic and management challenge for anesthesiologists under general anesthesia. CASE: A 68-year-old male undergoing bilateral laparoscopic adrenalectomy using a retroperitoneal approach developed progressive hypoxemia, hypercapnia, elevated peak inspiratory pressure, and hemodynamic instability approximately 4 h after surgical initiation. A minor diaphragmatic injury was identified and immediately repaired after reduction of pneumoretroperitoneum. Despite anatomical correction, respiratory and circulatory instability persisted, requiring high-dose vasopressor support and 100% inspired oxygen until the end of surgery. A radiograph obtained at the conclusion of surgery demonstrated marked mediastinal shift consistent with tension pneumothorax. The pneumothorax resolved spontaneously with supportive ventilation, and the patient recovered without chest tube insertion. CONCLUSION: This case highlights a physiological pitfall rather than a rare complication: even a minor diaphragmatic injury can result in sustained tension physiology despite timely anatomical repair during prolonged laparoscopic surgery. Continuous vigilance for evolving physiological abnormalities and proactive anesthesiologist-led management are essential.