Intraoperative management of a carbon dioxide embolus in the setting of laparoscopic cholecystectomy for a patient with primary biliary cirrhosis: A case report

Paradoxical carbon dioxide embolism during laparoscopic hepatectomy without intracardiac shunt: A case report

BACKGROUND

Laparoscopic hepatectomy has recently become popular because it results in less bleeding than open hepatectomy. However, CO₂ embolism occurs more frequently. Most CO₂ embolisms during laparoscopic surgery are self-resolving and non-symptomatic; however, severe CO₂ embolism may cause hypotension, cyanosis, arrhythmia, and cardiovascular collapse. In particular, paradoxical CO₂ embolisms are highly likely to cause neurological deficits. We report a case of paradoxical CO₂ embolism found on transesophageal echocardiography (TEE) during laparoscopic hepatectomy, although the patient had no intracardiac shunt.

CASE SUMMARY

A 71-year-old man was admitted for laparoscopic left hemihepatectomy. During left hepatic vein ligation, the inferior vena cava was accidentally torn. We observed a sudden drop in oxygen saturation to 85%, decrease in systolic blood pressure (SBP) below 90 mmHg, and reduction in end-tidal CO₂ to 24 mmHg. A “mill-wheel” murmur was auscultated over the precordium. The fraction of inspired oxygen was increased to 100% with 5 cmH₂O of positive end-expiratory pressure (PEEP) and hyperventilation was maintained. Norepinephrine infusion was increased to maintain SBP above 90 mmHg. A TEE probe was inserted, revealing gas bubbles in the right side of the heart, left atrium, left ventricle, and ascending aorta. The surgeon reduced the pneumoperitoneum pressure from 17 to 14 mmHg and repaired the damaged vessel laparoscopically. Thereafter, the patient’s hemodynamic status stabilized. The patient was transferred to the intensive care unit, recovering well without complications.

CONCLUSION

TEE monitoring is important to quickly determine the presence and extent of embolism in patients undergoing laparoscopic hepatectomy.

Pneumodissection during Percutaneous Renal Ablation Resulting in Air Embolism: Percutaneous Management and a Review of the Literature

Percutaneous renal ablation is a nephron-sparing approach for selected patients with renal cell carcinoma. Common complications include hemorrhage, injury to the urinary collecting system, and abscess formation. The purpose of this article is to present a case of vascular air embolism as a complication of pneumodissection performed during percutaneous ablation of renal cell carcinoma, discuss its successful percutaneous management, review common complications of renal ablation, and outline steps physicians can take to lessen these complications.

Venous carbon dioxide embolism during laparoscopic cholecystectomy a literature review

Laparoscopy has become the procedure of choice for routine gallbladder removal. A serious complication of this technique is the occurrence of gas emboli due to insufflation. It is associated with a high mortality rate of around 28%. The present systematic review intends to provide more insight into causes, symptoms and risk factors for this specific complication and to explore which measures should be taken to treat and prevent it. The Cochrane library and Pubmed were used as sources. Articles and their references were selected when they were related to the subject in sufficient detail. The course of this complication can vary from asymptomatic up to impairment of normal flow through the right ventricle (RV) or pulmonary artery, potentially leading to acute heart failure. The severity depends on the amount of gas, the rate of accumulation and the ability to remove the gas bubbles. It is difficult to estimate the true incidence of venous gas embolism during laparoscopic cholecystectomy as there are various diagnostic tools, each with different sensitivity. Precautions that need to be taken are: correct positioning of the needle, low insufflation pressure, low insufflation speed, screening for hypovolemia, Trendelenburg positioning, availability of intervention equipment at operation table, no placement of venous catheters during inspiration and catheter removing during expiration. Physicians need to be more aware of this harmful complication and the preventative measurements that need to be taken. As there are virtually no prospective data, future studies are needed to gain more knowledge on gas emboli during laparoscopic cholecystectomy.

Total laparoscopic retrieval of inferior vena cava filter

While there is some local variability in the use of inferior vena cava filters and there has been some evolution in the indications for filter placement over time, inferior vena cava filters remain a standard option for pulmonary embolism prophylaxis. Indications are clear in certain subpopulations of patients, particularly those with deep venous thrombosis and absolute contraindications to anticoagulation. There are, however, a variety of reported inferior vena cava filter complications in the short and long term, making retrieval of the filter desirable in most cases. Here, we present the case of a morbidly obese patient complaining of chronic abdominal pain after inferior vena cava filter placement and malposition of the filter with extensive protrusion outside the inferior vena cava. She underwent successful laparoscopic retrieval of her malpositioned inferior vena cava filters after failure of a conventional endovascular approach.