Multicavity gas migration following da Vinci 5 transoral robotic thyroidectomy in a 50-year-old male: a case report of successful conservative management

Introduction

Transoral robotic thyroidectomy (TORT) has emerged as preferred surgical option for patients with thyroid cancer who seek optimal cosmetic outcomes, as it leaves no visible cutaneous scars (1,2). To maintain the operative workspace, TORT requires continuous carbon dioxide (CO₂) insufflation. Although gas-related complications, such as subcutaneous emphysema, are relatively common, severe events, including pneumothorax or pneumomediastinum, remain rare (3,4).

The da Vinci 5 (DV5) system (Intuitive Surgical Inc., Sunnyvale, CA, USA) was recently introduced into clinical practice, representing a significant technological advance over prior generation platforms, including the da Vinci Xi and Si. A critical distinguishing feature of the DV5 is its integrated, actively regulated insufflation and smoke evacuation system. Unlike the Xi and Si platforms, which rely on separate, externally controlled insufflators that deliver gas in a compartmentalized and passive manner, the DV5 continuously modulated gas flow via automated algorithms designed to maintain target pressure and clear surgical smoke in real time. While this integration offers ergonomic and visibility advantages, its impact on local pressure gradients and gas dispersion within the anatomically confined working volumes of the transoral approach has not been systematically evaluated.

Current clinical guidelines and insufflation recommendations for TORT were developed based on experience with earlier platforms, and no DV5-specific protocols have yet been established. This knowledge gap is particularly consequential given the continuous fascial communication between the cervical visceral space, mediastinum, and retroperitoneum, which provides an anatomical pathway for extensive gas migration under pressure. Kwek et al. first reported pneumoperitoneum following transoral endoscopic thyroidectomy via the vestibular approach (TOETVA), demonstrating that CO₂ can traverse the full extent of the body’s fascial continuum without direct visceral injury (4). Subsequent reviews have confirmed that although severe gas-related complications are infrequent, they may produce life-threatening deterioration when they occur (3,5). As next-generation robotic platforms with novel gas management architectures are introduced into clinical practice, it is critical to prospectively evaluated whether complication profiles change and to develop platform-specific safety protocols accordingly.

We report a rare case of delayed, extensive multicavitary gas migration-involving simultaneous bilateral pneumothorax and pneumoretroperitoneum-following TORT performed with the DV5 system. This case represents one of the earliest documented TORT experiences with the DV5 platform in South Korea. We present this article in accordance with the CARE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0124/rc).

Case presentation

A 50-year-old male with no significant medical or smoking history was diagnosed with papillary thyroid carcinoma (PTC) of the left thyroid lobe. Preoperative evaluations, including chest and neck computed tomography (CT), revealed no underlying pulmonary disease, pleural abnormalities, or anatomical variations that might predispose to gas migration.

The patient underwent transoral robotic left hemithyroidectomy with central lymph node dissection using the DV5 system. The integrated smoke evacuation system was set to the “high” setting during flap creation and then switched to automated regulation mode following robot docking, in which the system autonomously adjusts gas flow to maintain target insufflation pressure. CO₂ insufflation was maintained at 8 mmHg with a flow rate of 20 L/min, consistent with parameters previously validated for TORT using earlier-generation platforms. No system alerts or pressure spike notifications were recorded in the DV5 integrated system log. Console time was 100 minutes, total operative time 170 minutes, and anesthesia duration 210 minutes. The procedure was technically uneventful, with successful preservation of the recurrent laryngeal nerve and parathyroid gland, and minimal blood loss (<10 mL).

Upon arrival in the post-anesthesia care unit (PACU), the patient was hemodynamically stable: heart rate 110 beats/min, blood pressure 140/80 mmHg, respiratory rate 12 breaths/min, and SpO₂ 97% on room air. However, approximately 20 min after admission, he developed acute-onset chest pain accompanied by progressive swelling of the neck. Physical examination revealed extensive subcutaneous emphysema diffusely involving the cervical region, with marked crepitus on palpation. He developed dyspnea with sudden SpO₂ decline to <90%. Emergency bedside chest radiography demonstrated simultaneous bilateral pneumothorax with subcutaneous emphysema of the neck and upper chest wall (Figure 1). Bilateral 20-Fr chest tubes were immediately inserted, resulting in rapid lung re-expansion and SpO₂ recovery to 97% within 10 minutes.

Figure 1 Emergent bedside chest radiograph (AP view) obtained 30 min after admission to the PACU. Simultaneous bilateral pneumothorax (arrows) and subcutaneous emphysema involving the neck and upper chest wall are demonstrated. AP, anteroposterior; PACU, post-anesthesia care unit.

Following transfer to the general ward, follow-up chest radiography demonstrated bilateral chest tubes in situ with re-expanded lungs and, unexpectedly, subdiaphragmatic free air (Figure 2). Abdominal CT was performed to exclude visceral injury and confirmed pneumoretroperitoneum and pneumoperitoneum, with gas distributed along the perirenal and pararenal spaces, without evidence of gastrointestinal perforation or other visceral trauma (Video 1). Chest CT demonstrated CO₂ tracking inferiorly from the cervical visceral space through the mediastinum into the retroperitoneal compartments along continuous fascial planes (Video 2).

Figure 2 Subsequent chest radiography (PA view) obtained after transfer to the general ward. Bilateral 20-Fr chest tubes are in situ with re-expansion of both lungs. Subdiaphragmatic free air is visible beneath the diaphragm, indicating concurrent pneumoperitoneum. PA, posteroanterior.

The patient was managed conservatively. Both chest tubes were removed on postoperative day (POD) 2. A follow-up chest radiograph prior to discharge confirmed complete re-expansion of both lungs with small residual pneumoperitoneum, consistent with the slower absorption of CO₂ in the peritoneal cavity (Figure 3). The patient was discharged on POD 4 without sequelae. Final pathology confirmed a 1.1-cm PTC with minimal extrathyroidal extension, staged pT1bN0M0.

Figure 3 Follow-up chest radiography (PA view) obtained prior to discharge following removal of all chest tubes. Both lungs remain fully expanded. Residual subdiaphragmatic free air reflects the expected slower natural absorption of CO₂ in the peritoneal cavity under conservative management. PA, posteroanterior.

All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board of Pusan National University Yangsan Hospital (No. 55-2026-007). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

TORT and TOETVA have gained widespread acceptance owing to their favorable cosmetic outcomes and minimally invasive nature, with complication rates comparable to open thyroidectomy in experienced hands (1,3,5). The absence of cutaneous incisions and the direct transmucosal approach via the oral vestibule confer superior cosmetic results, particularly relevant in younger patients and those with occupational or social concerns about visible scarring. However, CO₂ insufflation introduces a unique spectrum of gas-related complications rarely encountered in open surgery (3,5). Subcutaneous emphysema is relatively common and usually self-limited, whereas more severe manifestations-including pneumomediastinum, pneumothorax, and pneumoperitoneum-have been reported only sporadically (4,6,7).

Rare but potentially life-threatening complications, such as CO₂ embolism, have also been described, highlighting that insufflation-related mechanisms may underlie unexpected postoperative events independently of direct organ injury (8).

The present case is distinctive in that extensive multicavitary gas migration- bilateral pneumothorax and pneumoretroperitoneum-developed simultaneously in a delayed fashion after an initially stable postoperative course. The anatomical basis lies in the continuous fascial architecture of the cervical region: the pretracheal fascia encloses a visceral compartment that communicates directly with superior mediastinum, allowing insufflated gas to descend along tissue planes into the mediastinum. Mediastinal gas accumulation may subsequently cause pleural rupture and pneumothorax, while further caudal progression through diaphragmatic hiatus permits retroperitoneal and peritoneal extension (4). This mechanism is conceptually analogous to the Macklin effect described in pulmonary barotrauma, wherein gas dissects along bronchovascular sheaths under pressure; in the transoral setting, the analogous principle of least-resistance fascial dissection applies across the cervicofascial-mediastinal continuum.

The delayed onset of symptoms, approximately 20 minutes after arrival in the PACU, is mechanistically significant. During positive-pressure mechanical ventilation, elevated intrathoracic pressure may temporarily limit the expansion of mediastinal or paratracheal gas collections, effectively tamponading pleural defects. Upon transition to spontaneous respiration-during which intrathoracic pressure becomes negative during inspiration-previously contained gas collections may rapidly expand, unmasking or exacerbating pneumothorax (9). This mechanism likely explains the patient’s initial PACU stability followed by abrupt respiratory decompensation, and underscores the importance of sustained vigilance extending beyond the immediate post-extubation period.

From a technological perspective, the DV5’s integrated gas management system represents a fundamentally different paradigm from prior platforms. Whereas the Xi and Si relied on independent, passively controlled insufflators, the DV5 co-regulates insufflation and smoke evacuation via automated algorithms. Departing from the compartmentalized gas management of prior generations, this integrated platform potentially alters intraoperative pressure gradients, thereby facilitating extensive gas dispersion across contiguous fascial planes in restricted working volumes. Although no pressure alerts were captured in the DV5 system log in this case, continuous automated flow adjustments-particularly during the smoke evacuation phases-may generated transient pressure gradients not seen with conventional static insufflation, especially during deep cervicofascial dissection.

Large-scale analyses of robotic surgical adverse events have emphasized that complications may arise not only from surgical technique but also from system-level factors intrinsic to complex robotic platforms (2). Learning curve studies in TOETVA and TORT further suggest that complication patterns evolve with both surgeon’s experience and platform familiarity (6). As the DV5 represents a new generation with a still-emerging safety profile, its platform-specific gas dynamics warrant careful prospective evaluation as clinical experiences with the DV5 in South Korea, may serve as an important reference as adoption of the platform expands globally.

Based on this experience, we propose the following practical recommendations for surgeons adopting the DV5 for TORT: (I) consider reducing default insufflation pressure from 8 to 6 mmHg, as lower pressures have been shown adequate for workspace maintenance in TOETVA series (9); (II) switch automated smoke evacuation to manual or low-flow mode during deep dissection phases when fascial planes are most exposed; (III) maintain extended PACU monitoring for a minimum of 60 minutes post-extubation with a low threshold for emergency chest radiography if any respiratory symptoms develop; (IV) exercise heightened vigilance when postoperative anterior cervical crepitus is detected, as this may herald more extensive gas migration; and (V) conduct preoperative platform-specific briefings between surgeons, anesthesiologists, and DV5 system specialists, as the gas dynamics of this platform cannot be directly extrapolated from prior-generation systems.

Several limitations of this report deserve acknowledgment. First, this is a single case report and therefore cannot establish causality between DV5-specific gas dynamics and the observed complication. Whether the integrated smoke evacuation system directly contributed to the extent of gas migration-or whether this case represents a rare but inherent risk of TORT regardless of platform-cannot be determined from a single observation. Second, the DV5 system log reviewed in this case did not record pressure spike events; however, the granularity and completeness of automated logging for transient flow events during smoke evacuation cycles warrants further technical evaluation. Third, no control comparison between DV5 and prior-generation platform TORT outcomes is currently available, as the DV5 has only recently entered clinical practice. Prospective multicenter registries specifically designed to capture platform-specific gas-related adverse events during this early adoption period would be of considerable value.

Conclusions

CO₂ insufflation during TORT can result in extensive, multicompartmental gas migration even with standard pressure settings, and delayed symptom onset following the transition from positive-pressure ventilation to spontaneous respiration represents a critical vulnerability window that demands sustained postoperative vigilance. With the clinical adoption of the DV5 system, its integrated airflow and automated smoke evacuation system introduced platform-specific gas dynamics that cannot be directly extrapolated from prior-generation systems; surgeons, anesthesiologists, and technical teams must be aware of this distinction from the outset of platform adoption. Practical mitigation strategies-including reduced insufflation pressure, restricted automated smoke evacuation during deep dissection, and extended PACU monitoring for at least 60 minutes post-extubation-should be prospectively incorporated into institutional TORT protocols for the DV5. Although causality cannot be established from a single case, this report serves as an early sentinel event that justifies heightened attention to platform-specific safety during the current period of DV5 adoption. Prospective multicenter registries are needed to systematically characterize the gas-related complication profile of the DV5 system and to validate evidence-based insufflation protocols for next-generation robotic transoral surgery.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0124/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0124/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0124/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board of Pusan National University Yangsan Hospital (No. 55-2026-007). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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