Carbon dioxide embolism during laparoscopic cholecystectomy due to a patent paraumbilical vein

Carbon dioxide embolism is a rare but potentially fatal complication of laparoscopic surgery. The most common cause is inadvertent injection of carbon dioxide into a large vein or solid organ during initial peritoneal insufflation. We describe a case of carbon dioxide embolism in a 13-year-old boy during an elective laparoscopic cholecystectomy, caused by injection of carbon dioxide into a large paraumbilical vein. The clinical manifestations of carbon dioxide embolism were hypotension, bradycardia, and an abrupt drop in end-tidal CO₂. He subsequently did well and had no sequelae. Carbon dioxide embolism is a recognized complication of laparoscopic surgery, although the risk to the patient may be minimized by the surgical team's awareness of the problem, continuous intraoperative monitoring of end-tidal CO₂, and using an open technique for initial access to the peritoneum.     

Umbilical access in laparoscopic surgery in infants less than 3 months: A single institution retrospective review

IntroductionUmbilical access in laparoscopic surgery has been cited as a factor for increased complications in low-birth-weight infants and those less than three months old. In a previous series, 10.6% of pediatric surgeons reported complications in this population associated with umbilical access, citing carbon dioxide (CO₂) embolism as the most common complication. To further examine the safety of this technique, we report our outcomes with blunt transumbilical laparoscopic access at our institution over four years.MethodsA retrospective review was performed of patients less than three months of age who underwent laparoscopic pyloromyotomy or inguinal hernia repair from 2016 to 2019. Operative reports, anesthesia records, and postoperative documentation were reviewed for complications related to umbilical access. Complications included bowel injury, vascular injury, umbilical vein cannulation, CO₂ embolism, umbilical surgical site infection (SSI), umbilical hernia requiring repair, and death.ResultsOf 365 patients, 246 underwent laparoscopic pyloromyotomy, and 119 underwent laparoscopic inguinal hernia repairs. Median age at operation was 5.9 weeks [4.3,8.8], and median weight was 3.9 kg [3.4,4.6]. Nine complications (2.5%) occurred: 5 umbilical SSIs (1.4%), 1 bowel injury upon entry requiring laparoscopic repair (0.2%), 1 incisional hernia repair 22 days postoperatively (0.2%), and 2 cases of hypotension and bradycardia upon insufflation that resolved with desufflation (0.5%). There were no intraoperative mortalities or signs/symptoms of CO₂ embolism.ConclusionIn this series, umbilical access for laparoscopic surgery in neonates less than three months of age was safe, with minimal complications. Although concern for umbilical vessel injury, cannulation, and CO₂ embolism exists, these complications are not exclusively associated with umbilical access technique.     

Hepatic and portal vein blood flow during carbon dioxide pneumoperitoneum for laparoscopic hepatectomy

Background: Laparoscopy under carbon dioxide (CO₂) pneumoperitoneum has many advantages. However, the risks of CO₂ pneumoperitoneum during laparoscopic hepatectomy (LH) have not been defined. Methods: The hemodynamics of the hepatic vein were examined during CO₂ pneumoperitoneum both pre- and posthepatectomy in eight pigs. Portal blood flow was measured with Doppler ultrasound during laparoscopic cholecystectomy in 10 human patients. Results: Experimentally, elevated intraabdominal pressure (IAP) with CO₂ insufflation produced significant increases in CO₂ partial pressure and echogenicity of the hepatic vein in the posthepatectomy group. Clinically, elevated IAP caused significant narrowing of the portal vein and significant decreases in portal blood velocity. The mean portal flow was significantly decreased with elevation of IAP >10 mmHg. Conclusions: LH with CO₂ pneumoperitoneum may lead to embolism caused by CO₂ bubbling through the hepatic vein. Elevated IAP may cause a decrease in hepatic blood flow and induce severe liver damage, especially in patients with poor liver function. Gasless laparoscopy using abdominal wall lifting should be employed in LH to avoid the risks of CO₂ embolism and liver damage. Received: 28 March 1997/Accepted: 12 September 1997     

Portal venous flow during CO2 pneumoperitoneum in the rat

Backround: CO₂ gas insufflation is routinely used to extend the abdominal wall. The resulting pneumoperitoneum has a number of local and systemic effects on the organism. Portal blood flow, which plays an important role in hepatic function and cell-conveyed immune response, is one of the affected parameters. Methods: An established animal model (rat) of laparoscopic surgery was modified by implanting a perivascular flow probe. Hemodynamics in the portal vein were then measured during increasing intraabdominal pressure generated by carbon dioxide insufflation. Results: Using this technique, an adequate flowmetry of the portal vein was achieved in all animals. The creation of a CO₂ pneumoperitoneum with increasing intraabdominal pressure led to a linear decrease in portal venous flow. Conclusions: Elevated intraabdominal pressure caused by carbon dioxide insufflation may compromise hepatic function and cell-conveyed immune response during laparoscopic surgery. Received: 28 January 1998/Accepted: 22 June 1998     

Paradoxical carbon dioxide embolism during endoscopic thyroidectomy confirmed by transesophageal echocardiography

Carbon dioxide (CO₂) embolism is a rare but potentially life-threatening complication of laparoscopic procedures. Although endoscopic thyroidectomy using CO₂ gas insufflation appears to be superior to conventional open thyroidectomy in terms of cosmetic results, it may cause venous or fatal paradoxical CO₂ embolism. We report a case of paradoxical CO₂ embolism during CO₂ gas insufflation in an endoscopic thyroidectomy that was confirmed by transesophageal echocardiography (TEE). Paradoxical embolization via transpulmonary right-to-left shunting of venous CO₂ gas emboli was revealed by TEE examination. The patient recovered without complications. In conclusion, although endoscopic thyroidectomy is a promising approach that is gaining popularity and offers excellent cosmetic results compared with conventional open thyroidectomy, this case report emphasizes the importance of anticipating and being vigilant for potential CO₂ embolism.     

Gas embolism during laparoscopy

The use of laparoscopic surgery has grown considerably, and the occurrence of some accidents, albeit rare, is now reported. Among them, gas embolism can induce a bad postoperative outcome. We report seven cases of carbon dioxide embolism (CO₂) during laparoscopic surgery. In the seven cases gas embolism occurred during insufflation or a few minutes later. All the patients had a previous abdominal or pelvic surgical history. Five patients presented cardiac bradycardia or arrhythmia. Cardiovascular collapse or cyanosis was the first manifestation in three cases. Sudden bilateral mydriasis was the earliest neurologic sign, present in five cases. Finally, the gas embolism complication was lethal in two cases. In summary, this study strongly stresses the need for precise rules of prevention of gas embolism, and close monitoring of cardiac rhythm during insufflation of carbon dioxide. The patients who had previous surgery should be considered as a risk population.     

Does increasing end-tidal carbon dioxide during laparoscopic cholecystectomy matter?

To examine the adverse effects of peritoneal carbon dioxide (CO₂) insufflation during laparoscopic cholecystectomy, both hemodynamic and respiratory alterations were continously monitored in 17 adult patients using noninvasive Doppler ultrasonography and a continuous spirometric monitoring device. During the surgery, which was performed under inhalational general anesthesia, intraabdominal pressure was maintained automatically at 10mmHg by a CO₂ insufflator, and a constant minute ventilation, initially set to 30–33 mmHg of end-tidal CO₂ (ETCO₂), was maintained. Despite considerable depth of anesthesia, peritoneal CO₂ insufflation induced a significant and immediate increase of mean blood pressure (+42%) and systemic vascular resistance (+62%), accompanied by a slight depression of cardiac index (−12%, nonsignificant), while the ETCO₂ gradually increased and maximized around 30min following the initial CO₂ insufflation. The stress of 10mmHg pneumoperitoneum was a major cause of hemodynamic changes during laparoscopic cholecystectomy. Some clinical strategies such as deliberate intraabdominal insufflation at the initial phase might be required to minimize these hemodynamic changes.     

Gas embolus and cardiac arrest during laparoscopic pyloromyotomy in an infant

Purpose

High volume tubing is used to deliver carbon dioxide during laparoscopic procedures. Failure to prime the tubing with carbon dioxide prior to abdominal insufflation may result in the delivery of nitrogen-containing air to the abdominal cavity. We report a case in which initial insufflation of laparoscopic gas resulted in immediate cardiovascular collapse requiring prolonged resuscitation. Persistent intracranial emboli following the arrest may have resulted from nitrogen contamination of the delivered gas.

Clinical features

A 12-day-old female underwent laparoscopy for pyloric stenosis. During initial insufflation of the abdomen, the patient had an abrupt decrease in end-tidal carbon dioxide (CO_2ET) associated with bradycardia and pulseless electrical activity. Three hours after successful resuscitation and open pyloromyotomy, computerized tomography documented intra-arterial gas within the cerebral and hepatic circulations that resolved following hyperbaric oxygen therapy. Magnetic resonance imaging five days later revealed watershed infarcts in the right frontal and parietal regions. Nitrogen, an insoluble gas not easily eliminated from the body, was likely the gas present within the patient’s circulation several hours after the event. It was unlikely carbon dioxide, which is a highly soluble gas that binds to hemoglobin and is rapidly buffered by the carbonic anhydrase system and excreted by the lung. Room air contamination of high volume insufflation tubing allows nitrogen to enter body cavities during endoscopic procedures.

Conclusion

Persistence of emboli following endoscopic procedures suggests that the entrained gas is insoluble. Room air contamination increases the potential for catastrophic events during laparoscopy and other endoscopic procedures.     

Peritoneal and systemic pH during pneumoperitoneum with CO<Subscript>2</Subscript> and helium in a pig model

Background Local peritoneal effects of laparoscopic gases might be important in peritoneal biology during and after laparoscopic surgery. The most commonly used gas, CO₂, is known to be well tolerated, but also causes changes in acid-base balance. Helium is an alternative gas for laparoscopy. Although safe, it is not widely used. In this study a method for monitoring peritoneal pH during laparoscopy was evaluated and peritoneal pH during CO₂ and helium pneumoperitoneum was studied as well as its systemic reflection in arterial pH. Methods For these experiments 20 pigs were used, with ten exposed to pneumoperitoneum with CO₂, and ten to helium. Peritoneal and sub-peritoneal pH were continuously measured before and during gas insufflation, during a 30-minute period with a pneumoperitoneum and during a 30-minute recovery period. Arterial blood-gases were collected immediately before gas insufflation, at its completion, at 30 minutes of pneumoperitoneum and after the recovery period. Results Peritoneal pH before gas insufflation was in all animals 7.4. An immediate local drop in pH (6.6) occurred in the peritoneum with CO₂ insufflation. During pneumoperitoneum pH declined further, stabilising at 6.4, but was restored after the recovery period (7.3). With helium, tissue pH increased slightly (7.5) during insufflation, followed by a continuous decrease during pneumoperitoneum and recovery, reaching 7.2. Systemic pH decreased significantly with CO₂ insufflation, and increased slightly during helium insufflation. Systemic pH showed co-variation with intra-peritoneal pH at the the end of insufflation and after 30 minutes of pneumoperitoneum. Conclusions Insufflation of CO₂ into the peritoneal cavity seemed to result in an immediate decrease in peritoneal pH, a response that might influence biological events. This peritoneal effect also seems to influence systemic acid-base balance, probably due to trans-peritoneal absorption.     

Arterial to endtidal carbon dioxide gradient during pediatric laparoscopic fundoplication

Background: Discrepancies between arterial carbon dioxide (P_aCO₂) and endtidal carbon dioxide (ETCO₂) measures have been demonstrated in ventilated children with cyanotic congenital heart disease, infants with respiratory failure and during visceral and urological laparoscopic surgery. Objectives: Our objective was to assess the extent of the P_aCO₂ to ETCO₂ gradient in children during laparoscopic fundoplication. Methods: We prospectively collected data on patient characteristics, surgical conditions, pH, ETCO₂and P_aCO₂ during laparoscopic fundoplication using carbon dioxide insufflation in children age <29 months. Results: Data were collected on nine cases, four cases aged <1 year. A P_a‐ETCO₂ gradient was present during insufflation. The gradient was larger in children age less than 1 year but statistically significantly different from a value of zero, only at t = 30 min (mean = 8 mmHg, sem = 0.81, P = 0.004) and t = 60 min (mean = 5 mmHg, sem = 1, P = 0.014). Minute ventilation was increased from 20% to 100% to control ETCO₂. Conclusions: ETCO₂ may not accurately represent arterial values during laparoscopic fundoplication, especially in the infant when carbon dioxide insufflation is used. Consideration should be given to placing an arterial line for blood gas measurement in some patients.     

Prolonged intraperitoneal versus extraperitoneal insufflation of carbon dioxide in patients undergoing totally endoscopic robot-assisted radical prostatectomy

Background Extraperitoneal laparoscopic prostatectomy is an alternative to the intraperitoneal method. However, the effects of extraperitoneal carbon dioxide (CO₂) insufflation on hemodynamics and respiratory data have not been adequately studied. This study compared the effects of prolonged intra- and extraperitoneal CO₂ insufflation on hemodynamics and gas exchange.Methods For this study, 20 patients were assigned to receive totally endoscopic robot-assisted radical prostatectomy (TERP) via the intra- or extraperitoneal approach. Hemodynamic parameters and respiratory data were obtained during 8 h of insufflation and analyzed for statistical differences.Results With both insufflation methods, arterial CO₂ pressure increased rapidly, reaching higher levels with extraperitoneal insufflation. Therefore, patients managed with extraperitoneal insufflation required a significantly higher minute ventilation. Heart rate and central venous pressure increased in both groups, whereas mean arterial blood pressure and pH decreased.Conclusions Prolonged intra- and extraperitoneal CO₂ insufflation for TERP resulted in significant, but mostly clinically unimportant, hemodynamic alterations. Carbon dioxide absorption was more pronounced with extraperitoneal insufflation.     

A randomized controlled trial assessing the benefit of humidified insufflation gas during laparoscopic surgery

Background: We conducted a randomized controlled trial during laparoscopic cholecystectomy to determine the extent of heat preservation and postoperative pain reduction using humidified carbon dioxide (CO₂) gas insufflation instead of standard dry insufflation gas.     

Does hypocapnia before and during carbon dioxide insufflation attenuate the hemodynamic changes during laparoscopic cholecystectomy?

Background  

Hypocapnia before and during carbon dioxide (CO₂) insufflation for laparoscopic cholecystectomy may reduce the adverse hemodynamic responses.     

MAJOR VASCULAR INJURY AND LAPAROSCOPY

Iatrogenic vascular trauma is a hazard that must be considered constantly during any laparoscopic procedure. We present a case of vessel penetration presenting as CO₂ embolism during insufflation where delayed recognition of the vascular implications of this event led to death from exsanguination. The pattern of laparoscopic vascular injuries in Australia as reported to the Medical Defence Union (UK) and the New South Wales Medical Defence Union is reviewed and compared with previously reported cases of vascular trauma in laparoscopy. Recommendations are made for the diagnosis and most importantly for the prevention of CO₂ embolism and major vascular injury at laparoscopy.     

Myopéricardite aiguë dans les suites d'une cure laparoscopique de reflux gastro-œsophagien

A 32-year-old patient experienced a postoperative acute myopericarditis following laparoscopic surgery for gastrooesophageal reflux (Toupet's fundoplication). His medical history was unremarkable, apart from controlled arterial hypertension. Peroperative circulation was stable, except a short hypertensive episode at CO₂ insufflation, controlled with nicardipine. A myopericarditis occurred at the fourth postoperative hour, with apical and inferior hypokinesia at ventriculography, ST-segment elevation with unremarkable coronary arteriography. The patient was discharged at day seven, with a NSAIDs treatment. Echocardiography three and nine months later postoperatively, showed an apical akinesia and persistence of the ST-segment modification, without clinical symptoms. Complications of laparoscopic fundoplication is either specific to surgery (gastro-oesophageal injury, diaphragmatic injury, mediastinitis, stenosis) or secondary to pneumoperitoneum (Pneumothorax, carbon dioxide embolism). In this case, following an apparently uncomplicated laparoscopy and, except a direct cardiac trauma from a laparoscopic instrument, either coronary artery spasm, or pneumopericardium with CO₂, or delayed gas embolism, or preoperative “silent” myopericarditis could be the potential cause of this cardiac complication.     

腔镜甲状腺手术CO_2气腹对颈内静脉压力及中心静脉压的影响

目的:探讨腔镜下胸乳入路甲状腺手术CO_2气腹对颈内静脉压力及中心静脉压的影响。方法:30例患者经胸乳入路行腔镜下甲状腺手术,分别于CO_2充气前,充气后10 min、20 min、40 min,关闭充气后5 min、20 min测量颈内静脉压力、中心静脉压,比较不同时点颈内静脉压力、中心静脉压的变化。结果:与充气前相比,充气后各时点的颈内静脉压力、中心静脉压显著上升(P0.05);解除充气后,逐渐下降,与充气前相比差异无统计学意义(P0.05);充气后三个时间点的颈内静脉压力均大于8 mmHg(P0.05),中心静脉压均小于8 mmHg(P0.05)。结论:经胸乳入路腔镜甲状腺手术中CO_2气腹会导致颈内静脉压力、中心静脉压显著升高,切除甲状腺中上部时无发生气体栓塞的可能,但切除甲状腺下部时有发生气体栓塞的可能。     

Hemodynamics during laparoscopic extra- and intraperitoneal insufflation

Background: Total extraperitoneal laparoscopic surgery is an alternative to the laparoscopic transperitoneal route; however, its effects on hemodynamics have not been adequately studied. This experimental study compared the effects of intraperitoneal insufflation and extraperitoneal insufflation on hemodynamics and oxygen transport. Methods: Sixteen pigs were randomly assigned for intraperitoneal insufflation or extraperitoneal insufflation with 15 mmHg carbon dioxide. Hemodynamic and oxygen transport parameters were taken during an hour of insufflation and analyzed for statistical differences. Results: During extraperitoneal CO₂ pneumoperitoneum central venous filling pressures (central venous pressure, pulmonary capillary wedge pressure and mean pulmonary arterial pressure) and end-tidal CO₂ increased slower but to a similar magnitude in comparison to intraperitoneal insufflation. Cardiac output and indices of oxygen consumption and oxygen delivery were equally affected by both types of insufflation. Arterial CO₂ pressure increased significantly more during intraperitoneal insufflation. Conclusion: The data from this study suggest that extraperitoneal insufflation might result in less cardiovascular impairment than intraperitoneal insufflation.     

Venous gas embolism — a comparison of carbon dioxide and helium in pigs

Purpose

The use of helium for insufflation during laparoscopic surgery avoids hypercarbia and acidosis associated with absorbed CO₂, but the effects of helium gas embolism are unknown. We compared the effects of CO₂ with He gas embolism on survival, haemodynamic variables, oxygenation, and ventilation in pigs.

Methods

Anaesthetized juvenile pigs were given progressively larger boluses of either CO₂ (n=5) or He (n=4) into the right atrium. Measurements of haemodynamic vanables, oxygenation, and P_ETCO₂ were made before and after each gas injection.

Results

All animals survived injections of 300 ml CO₂ while no animal survived more than 120 ml He (P < 0.01). Mean arterial pressure decreased more after 60 ml He (99 ±14 to 44 ±20 mmHg) than after 60 ml CO₂ (110 ±12 to 88 ±14 mmHg, P < 0.001). Cardiac output did not change at any injection volume. The P_ETCO₂ decreased more after 60 ml He (30 ±2 to 3 ±6 mmHg) than after 60 ml CO₂ (35 ±3 to 30 ±3 mmHg, P < 0.001). Only the He group showed a decrease in PaO₂ (190 ±51 to 68 ±22 mmHg at 60 ml, P < 0.05).

Conclusion

Helium gas embolism has a greater deleterious effect than CO₂ gas embolism on survival, MAR P_ETCO₂, and PaO₂. These different effects of gas embolism should be recognized when considering the use of helium or other insoluble gases for abdominal laparoscopic insufflation.     

Tumor implantation following laparoscopy using different insufflation gases

Background: Laparoscopic manipulation of malignancies is associated with an increased incidence of metastasis to port sites in experimental models. This study investigated the effect of different insufflation gases on the implantation of a tumor cell suspension following laparoscopic surgery in an established small animal model. Methods: Forty Dark Agouti rats underwent laparoscopy and the introduction into the peritoneal cavity of a tumor cell suspension. The insufflating gas used for each procedure was one of the following gases (10 rats in each group): carbon dioxide (CO₂), nitrous oxide (N₂O), helium, and air. The rats were killed 7 days after surgery, and the peritoneal cavity and port sites were examined for the presence of tumor. Results: Although no significant differences were seen between air, CO₂, and N₂O insufflation groups, tumor involvement of peritoneal surfaces was less likely following helium insufflation. Conclusion: The results of this study suggest that tumor metastasis to port sites following laparoscopic surgery may be influenced by the choice of insufflation gas. In this study, helium was associated with reduced tumor growth.     

Effects of carbon dioxide vs helium pneumoperitoneum on hepatic blood flow

Background: Elevated intraabdominal pressure due to gas insufflation for laparoscopic surgery may result in regional blood flow changes. Impairments of hepatic, splanchnic, and renal blood flow during peritoneal insufflation have been reported. Therefore we set out to investigate the effects of peritoneal insufflation with helium (He) and carbon dioxide (CO₂) on hepatic blood flow in a porcine model. Methods: Twelve pigs were anesthetized and mechanically ventilated with a fixed tidal volume after the stabilization period. Peritoneal cavity was insufflated with CO₂ (n= 6) or He (n= 6) to a maximum intraabdominal pressure of 15 mmHg. Hemodynamic parameters, gas exchange, and oxygen content were studied at baseline, 90 mm and 150 min after pneumoperitoneum, and 30 min after desufflation. Determination of hepatic blood flow with indocyanine green was made at all measured points by a one-compartment method using hepatic vein catheterization. Results: A similar decrease in cardiac output was observed during insufflation with both gases. Hepatic vein oxygen content decreased with respect to the baseline during He pneumoperitoneum (p < 0.05), but it did not change during CO₂ insufflation. Hepatic blood flow was significantly reduced in both the He and CO₂ pneumoperitoneums at 90 min following insufflation (63% and 24% decrease with respect to the baseline; p < 0.001 and p < 0.05, respectively) being this decrease marker in the He group (p= 0.02). Conclusions: These findings suggest that helium intraperitoneal insufflation results in a greater impairment on hepatic blood flow than CO₂ insufflation. Received: 27 March 1996/Accepted: 19 January 1997