HYDROTHORAX ; A COMPLICATION OF SUPRACOSTAL APPROACH IN PCNL

A 48 year old gentleman underwent bilateral PCNL( simultanoeus and with multiple punctures)The main bulk of the stone was removed with the supracostal and upper calyceal approach.

The patient post-operatively had a drop in saturation after a period of 2 hours.The auscultation was normal during the operation but in the second hour of the operation it was noted that airway pressures had risen and saturation started dropping.We placed  thorax tube  on both sides and 800 ml fluid was drained from left side and 1000 ml was drained from right side.

As there is a drop of saturaion we did it on an emergency basis without going ahead for CxRay. 

BILATERAL ICD IN SITU

Especially supracostal approach carries a higher risk of intrathoracic complications.Prone position is required for PCNL. Munshi et al. reported that they were also not able to recognize hydrothorax in a similar patient until the end of the operation and blamed the prone position. Hydrothorax was realized after the spontaneous ventilation was achieved and the patient was in supine position. 

Technique to avoid hydrothorax:

The puncture should be done after deciding the right calyx and approach to the calyx to be punctured decided ; in a fully expiration.Once the needle is placed and is in perinephric tissues then the final puncture should be done in full inspiration.