volvulus underwent laparoscopic fundoplication with crural repair and anterior gastropexy. Insufflation with carbon dioxide distended a large hiatal hernia sac, enabling good vision of the hiatal structures. During dissection of the oesophagus, however, the left pleura was breached resulting in collapse of the hernial sac from gas entering the left pleural space, obliterating the view within the sac. Again, there was no associated hypoxia or haemodynamic compromise, enabling the procedure to progress uneventfully. Postoperative chest radiography showed pneumomediastinum but no pneumothorax. As carbon dioxide is highly water-soluble, small amounts of the gas in the pleural cavity will be rapidly resorbed.
While we agree with Reid et al. that pneumothorax associated with hypoxia and hypotension mandates stopping the operation to confirm the diagnosis, deflate the abdomen and place a chest drain, pneumothorax without associated problems does not require any of these manoeuvres. Postoperative chest radiography is probably sufficient. A small pneumothorax will resorb rapidly; a iarge pneumothorax is probably best managed by aspiration rather than chest drainage in the first instance.