A Case Report of Severe Subcutaneous Emphysema Requiring Tracheostomy Following Robot-Assisted Laparoscopic Pancreatectomy

Subcutaneous emphysema following robotic surgery is a recognized complication, but progression to severe airway compromise is rare. This report discusses unique risk factors and management challenges in an obese patient, contrasting with typical presentations in underweight individuals. An 81-year-old obese female (BMI 26.5 kg/m²) underwent a prolonged (8.9 hours) robot-assisted distal pancreatectomy. She developed extensive subcutaneous emphysema extending to her neck and face, causing severe pharyngeal edema that precluded extubation. Airway management required continued intubation and a tracheostomy on postoperative day 4. The prolonged emphysema resolved in 17 days. This case underscores the need for a high index of suspicion for severe emphysema in patients with any body habitus during prolonged surgery. It also highlights the paramount importance of a cautious airway strategy, prioritizing safety over early extubation when emphysema involves the neck.