WOFAPS 2025 8th World Congress of Pediatric Surgery

Arije Zouaoui, Yasmine Houas, Abir Jouini, Yosra Kerkeni, Riadh Jouini

Pediatric Surgery Department, Children's Hospital Bechir Hamza, Tunis, Tunisia

Introduction:
Pneumoperitoneum is typically considered a surgical emergency, often resulting from gastrointestinal perforation or barotrauma, especially in neonates. However, benign pneumoperitoneum—a rare entity in older infants—can mimic surgical emergencies but may not require operative intervention. We report a rare case of idiopathic non-neonatal pneumoperitoneum in a 4-month-old infant, aiming to highlight the diagnostic challenges and therapeutic strategies in this unusual clinical scenario.

Case Presentation:
A 4-month-old boy, recently operated for tetralogy of Fallot, was admitted to the intensive care unit for postoperative care. After progressive weaning from mechanical ventilation, the patient developed sudden and severe abdominal distension, impairing ventilation and causing lower limb collapse. Abdominal radiography revealed a massive pneumoperitoneum. Given the hemodynamic instability and clinical suspicion of gastrointestinal perforation, an urgent exploratory laparotomy with Kocher maneuver was performed. Intraoperatively, the entire gastrointestinal tract was found intact without any perforation or congenital anomaly. Postoperatively, the patient showed rapid clinical improvement: ventilatory support was discontinued within 24 hours, and oral feeding resumed on postoperative day two. The clinical course was uneventful.

Conclusion:
Idiopathic pneumoperitoneum is a rare and often misunderstood condition outside the neonatal period. Distinguishing benign from surgical pneumoperitoneum remains challenging, particularly in non-neonatal patients, leading to potential overtreatment. This case underscores the need to refine diagnostic criteria and therapeutic guidelines for pneumoperitoneum, integrating clinical presentation, radiological findings, and etiology. Establishing absolute surgical indications and clear criteria for conservative management could prevent unnecessary surgeries and improve outcomes in selected patients.