Postoperative subcutaneous emphysema following percutaneous
A 71 years old obese female, known case of hypertension, well-controlled on medications, presented to the outpatient clinic with a history of on and off left flank pain for 6 months. Her condition was associated with on and off fever, occasional dark stained urine with increased frequency. Her preoperative investigations were unremarkable but her urine culture was positive for gram-negative rods sensitive to ciprofloxacin, which was treated with oral ciprofloxacin according to the sensitivity pattern. Her Computed Tomography (CT) scan showed bilateral partial stage horn stones, measuring 3.4 × 1.8 mm on the right side and 2.6 × 2.1 cm on the left side.

She was planned for elective PCNL on the left side. The procedure was performed in a prone position by a specialist Urologist. A lower pole puncture was done under fluoroscopic guidance and the tract was dilated using serial metallic dilators up to 28 Fr. The puncture site was below the 12th rib and posterior to the posterior axillary line. The stone was fragmented using pneumatic lithoclast and fragments were retrieved. A nephrostomy tube was placed at the end of the procedure. Postoperatively the patient was vitally stable. The next day patient remained stable and was mobilized. Her urine output and nephrostomy output were clear, so both Foley's catheter and nephrostomy were eventually removed. Her postoperative laboratory work-up that included a complete blood picture and renal function were within normal limits and was eventually discharged home.

On follow up, 4th Postoperative day as an outpatient she reported abdominal pain, more on left flank associated with anorexia, constipation, nausea, non-projectile vomiting and low grade fever. On examination she was noted to be febrile (37.8 °C) and tachycardic (110b/min), there was mild erythema around the puncture site as well as significant subcutaneous emphysema on the left flank extending anteriorly towards epigastrium and left iliac fossa was noted. On expression, foul-smelling purulent discharge was seen from the puncture site. Auscultation of the bowel had decreased bowel sounds Abdominal X-ray was done which showed air in the left iliac fossa.

She was admitted and her septic workup was done and a CT scan was ordered which showed significant air in the left retroperitoneal space. There was no evidence of any bowel perforation, lung, or pleural injury. She underwent daily dressing and was started empirically on intravenous antibiotics. Her Repeat Urine culture showed Klebsiella oxytoca and Pus Culture showed E. coli, which were treated with Injection Meropenem. She improved clinically after the initiation of antibiotics and inflammatory markers subsequently settled. Subcutaneous emphysema reduced spontaneously with time and was discharged home with daily dressing. She was followed up 4 weeks postoperatively, her wound had completely healed and subcutaneous emphysema resolved completely.