Cardiopulmonary complications during laparoscopy: two case reports

Using LAP PROTECTOR™ to prevent subcutaneous emphysema after robotic gastrectomy

Subcutaneous emphysema (SE), a complication of robotic gastrectomy (RG), occurs when the gas used to establish pneumoperitoneum escapes and enters the soft tissue. SE typically does not result in major clinical problems, but massive SE can have life-threatening consequences. Hence, developing adequate preventive methods against postoperative SE is essential. We aimed to determine whether an existing protective device, the LAP PROTECTOR™ (LP), can be used to reduce the incidence of SE after RG. We analyzed the data of 194 patients who underwent RG at our hospital between August 2016 and December 2022. Since September 2021 (the 102nd patient), we have used the LP (FF0504; Hakko Medical, Hongo, Tokyo, Japan) at the trocar site, as this was expected to reduce the incidence of SE. The primary endpoint of this study was the efficacy of the LP in reducing the incidence of clinically relevant SE (defined as SE extending into the cervical area) a day after RG. Univariate analysis revealed that sex, body mass index (BMI), and LP usage differed significantly between patients with and without postoperative SE. Logistic regression analysis revealed that male sex (odds ratio [OR]: 0.22, 95% confidence interval [CI]: 0.15-0.72, P < 0.001), high BMI (OR: 0.13, 95% CI: 1.23-4.45, P = 0.009), and LP usage (OR: 0.11, 95% CI: 0.04-0.3, P < 0.001) were preventive factors independently associated with a lower incidence of clinically relevant SE. Placing an LP at the trocar site may be a safe and effective method of preventing SE after RG.

Comparison of valve-less and standard insufflation on pneumoperitoneum-related complications in robotic partial nephrectomy: a prospective randomized trial

To prospectively compare standard and valve-less insufflation systems on pneumoperitoneum-related complications in robotic-assisted laparoscopic partial nephrectomy. A prospective randomized controlled trial was conducted during a 1.5-year period to compare insufflation-related complications in partial nephrectomy surgery by a single surgeon. Thirty-one patients were recruited for each group: AirSeal insufflation system at 12 mmHg (AIS12), AirSeal at 15 mmHg (AIS15), and conventional insufflation system at 15 mmHg (CIS). Primary outcome assessed was rate of subcutaneous emphysema. Secondary outcomes included rates of pneumothorax, pneumomediastinum, shoulder pain scores, overall pain scores, pain medication usage, insufflation time, recovery room time, length of hospital stay and impact of surgical approach. Predictors for subcutaneous emphysema were assessed with univariate and multivariate logistic models. 93 patients with similar baseline characteristics were randomized into the three insufflation groups. Incidence of subcutaneous emphysema was lower in the AIS12 group compared to CIS (19% vs 48%, p = 0.03,). Mean pain score was less for AIS12 compared to CIS at 12 h (3.1 vs 4.4, p = 0.03). Shoulder pain was less in AIS12 and AIS15 groups compared to CIS at 8 h (AIS12 vs CIS: 0.6 vs 1.6, p = 0.01, AIS15 vs CIS: 0.6 vs 1.6, p = 0.02), and between AIS12 as compared to CIS at 12 h (0.4 vs 1.4, p = 0.003) postoperatively. There was no difference between morphine equivalent use, insufflation time, recovery room time, and length of hospital stay. Multivariable regression analysis showed AirSeal at 12 mmHg and the transperitoneal approach to be the only significant predictors for lower risk of developing subcutaneous emphysema (p < 0.001). Compared to standard insufflation, AirSeal insufflation at 12 mmHg was associated with reduced risk of developing subcutaneous emphysema in robotic partial nephrectomy. Furthermore, shoulder pain was reduced in both AirSeal groups compared to standard insufflation. The retroperitoneal approach increases the risk of developing subcutaneous emphysema.

The role of anticholinergic medication in the prevention of bradycardia during laparoscopic gynaecological surgery

Bradycardia and cardiac arrest are recognised complications of laparoscopic gynaecological surgery. Anticholinergic agents are indicated in the treatment of perioperative bradyarrhythmia; however, their role in the prevention of bradycardia as a result of insufflation of the peritoneum is less well defined. This article systematically reviewed the literature with respect to the role of anticholinergic agents in the prevention of clinically significant bradyarrhythmia during laparoscopic gynaecological surgery. Eight studies were included for review following an extensive database search. This review highlights the paucity of evidence supporting the prophylactic use of anticholinergic agents in preventing clinically significant bradycardia in women undergoing laparoscopic gynaecological surgery.

Pneumomediastinum and subcutaneous emphysema after successful laparoscopic supra-cervical hysterectomy

Laparoscopic hysterectomy is a commonly performed gynecological procedure. Although the outcomes are favorable, severe life threatening complications such as pneumothorax, pneumomediastinum and subcutaneous emphysema can occur during laparoscopy secondary to carbon dioxide insufflation. We report a 46-year-old female who was scheduled for laparoscopic-assisted supra-cervical hysterectomy for uterine fibroids. Patient tolerated the procedure and there were no intra-operative complications. Post operatively she developed hypercarbia, subcutaneous emphysema and pneumomediastinum. She was managed conservatively. This case demonstrates a rare occurrence of subcutaneous emphysema and pneumomediastinum after supra-cervical hysterectomy.

Iatrogenic Lower Extremity Subcutaneous Emphysema after Prolonged Robotic-Assisted Hysterectomy

Subcutaneous emphysema is a known complication of carbon dioxide insufflation, an essential component of laparoscopy. The literature contains reports of hypercarbia, pneumothorax, or pneumomediastinum. However, isolated lower extremity subcutaneous emphysema remains a seldom-reported complication. We report a case of unilateral lower extremity subcutaneous emphysema following robotic-assisted hysterectomy, bilateral salpingooophorectomy, staging, and anterior/posterior colporrhaphy for carcinosarcoma and vaginal prolapse. On postoperative day 1, the patient developed tender crepitus and bruising of her right ankle. Radiography confirmed presence of subcutaneous air. Vital signs and laboratory findings were unremarkable. Her symptoms spontaneously improved over time, and she was discharged in good condition on day 2. In stable patients with postoperative extremity swelling or pain with crepitus on exam, the diagnosis of iatrogenic subcutaneous emphysema must be considered.

Laparoscopic colorectal surgery is safe and benefits octogenarian patients with malignant disease: a matched case-control study comparing laparoscopic and open colorectal surgery

PURPOSE

Increased physiological stress from laparoscopic surgery and the lower physiological reserves in the elderly are causes for concern. This study aims to compare the outcomes between laparoscopic and open colorectal surgery in octogenarians.

METHODS

Octogenarians who underwent elective colorectal resections from 2000 to 2011 were reviewed. Patients who underwent laparoscopic surgery were matched for comorbidities, T-staging and type of resection performed to patients with open surgery.

RESULTS

Each group had 36 patients. Both groups were comparable for median age (85 vs 83, p = 0.43), gender (21 vs 18 males, p = 0.64) and the American Society of Anaesthesiologists (ASA) score (p = 0.486). Both groups had comparable median maximal tumour dimensions (4.75 vs 4.25 cm, p = 0.38) and median number of lymph nodes harvested (15 vs 14, p = 0.94). The laparoscopic group had, however, a longer median operative time (167.5 vs 124.5 min, p < 0.001). Both groups had comparable median length of hospitalisation (8 vs 7, p = 0.83), number of complications with a grade of complication (GOC) of ≥3 (5 vs 7, p = 0.75) and 30-day mortality rates (8.3 vs 5.6%, p = 1.00). One-year survival rate for the open group was lower (75.0 vs 94.4%, p = 0.09).

CONCLUSIONS

Despite a longer operating time, laparoscopic surgery had comparable short-term outcomes and might have a long-term survival benefit.

Subcutaneous emphysema in the lower extremities-always an emergency? Complications from minimally invasive surgery-a case report

BACKGROUND

Lower-extremity subcutaneous emphysema is an unusual presentation in the emergency department, and it is often associated with gas-forming bacterial infections that confer significant morbidity and mortality. Because the presence of subcutaneous emphysema in an extremity can be alarming, physicians often pursue aggressive diagnostic and therapeutic strategies to identify and treat the underlying cause. In some cases, however, subcutaneous emphysema does not represent a life-threatening medical condition. The source of the subcutaneous air may not always be immediately recognized and can lead to either over- or under-utilization of resources to direct patient care.

CASE REPORT

We describe a case of bilateral lower-extremity subcutaneous emphysema after recent robotic surgery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As the role of minimally invasive surgery and the push for shorter hospitalizations continue to rise, we are likely to see an increase in patients with complications from such procedures in the emergency department setting. Familiarity with the potential complications of these procedures is essential to differentiating between life-threatening and non-life-threatening conditions.

Grossly delayed massive subcutaneous emphysema following laparoscopic left hemicolectomy: A case report

INTRODUCTION

Surgical emphysema is a known early complication of laparoscopic surgery, common during upper gastrointestinal and gynaecological surgery; the authors present the first case of delayed subcutaneous emphysema following a laparoscopic left hemicolectomy.

PRESENTATION OF CASE

A 52-year-old woman underwent a laparoscopic left hemicolectomy for a sigmoid malignancy; on the third post-operative day after an uneventful procedure, she developed a massive surgical emphysema involving her face, neck and chest with associated pneumoperitoneum but without any evidence of pneumothorax. A gastrograffin enema ruled out an anastomotic leak. Apart from a borderline tachycardia, mildly low saturations and an area of erythema in her right flank, she was totally asymptomatic. The emphysema resolved spontaneously around the 6th post-operative day.

DISCUSSION

Massive subcutaneous surgical emphysema after laparoscopic colorectal surgery is a rare complication and can me managed conservatively with a good outcome.

CONCLUSION

To our knowledge, this represents the first case of delayed massive surgical emphysema following colorectal surgery, the aetiology of which has still not been clearly explained, after exclusion of the most common causes.

Massive subcutaneous emphysema in robotic sacrocolpopexy

Robotic sacrocolpopexy may increase insufflation complications including massive subcutaneous emphysema.

The advent of robotic surgery has increased the popularity of laparoscopic sacrocolpopexy. Carbon dioxide insufflation, an essential component of laparoscopy, may rarely cause massive subcutaneous emphysema, which may be coincident with life-threatening situations such as hypercarbia, pneumothorax, and pneumomediastinum. Although the literature contains several reports of massive subcutaneous emphysema after a variety of laparoscopic procedures, we were not able to identify any report of this complication associated with laparoscopic or robotic sacrocolpopexy. Massive subcutaneous emphysema occurred in 3 women after robotic sacrocolpopexy in our practice. The patients had remarkable but reversible physical deformities lasting up to 1 week. A valveless endoscopic dynamic pressure system was used in all 3 of our cases. Our objective is to define the risk of massive subcutaneous emphysema during robotic sacrocolpopexy in light of these cases and discuss probable predisposing factors including the use of valveless endoscopic dynamic pressure trocars.

Nitrogenous subcutaneous emphysema caused by spray application of fibrin glue during retroperitoneal laparoscopic surgery

We report a case of a patient treated by retroperitoneoscopic partial nephrectomy who developed nitrogenous subcutaneous emphysema (SCE) as a complication. The use of a nitrogen gas-pressured fibrin tissue adhesive applied as a spray caused excessively increased pressure in the closed retroperitoneal space and resulted in widespread SCE with protracted clinical course. To the best of our knowledge, this is the first report of nitrogenous SCE associated with pneumoperitoneum. The clinical significance of nitrogenous SCE is emphasized, and the risks associated with the use of fibrin glue as a spray during laparoscopic surgery are discussed.

Spontaneous resolution of massive laparoscopy-associated pneumothorax: the case of the bulging diaphragm and review of the literature

A massive left-side pneumothorax was identified intraoperatively on the basis of bulging left hemidiaphragm toward the end of an uncomplicated laparoscopic Nissen fundoplication. There were no changes in ventilatory or hemodynamic parameters. The pneumothorax was observed, and nearly total spontaneous resolution occurred in the recovery room within 1 hour.

Laparoscopic management of suspicious ovarian cysts in elderly, postmenopausal women

OBJECTIVES

To present our experience with laparoscopic treatment of ovarian cysts in elderly, postmenopausal women.

STUDY DESIGN

During the period January 1996 to August 1997, 21 elderly, postmenopausal women were admitted to the Rabin Medical Center for laparoscopy. The indications for the operation were an ovarian cyst that did not meet the criteria of a simple cyst, was larger than 4 cm, had pathological Doppler flow or elevated CA-125 level.

RESULTS

The median age of the patients was 67.19 (range 60-74). Despite the fact that 15 (71.4%) of the patients suffered from chronic disease, all laparoscopies were successfully accomplished. No case of malignancy was found.

CONCLUSIONS

Laparoscopic management of carefully selected ovarian cysts is an appropriate alternative for exploratory laparotomy even in elderly patients with or without underlying diseases.

Repercussões do pneumoperitônio sobre o sistema venoso dos membros inferiores-estudo em porcas

A trombose venosa profunda e a embolia pulmonar são complicações dos atos cirúrgicos nem sempre diagnosticadas. Nas operações pela via laparoscópica, a insuflação do CO2 na cavidade peritoneal é provavelmente a principal determinante da estase venosa nos membros inferiores. Este trabalho foi realizado com a finalidade de determinar a influência do pneumoperitônio na dinâmica circulatória dos membros inferiores. Distribuíram-se trinta porcas em três grupos: sem pneumoperitônio, com pneumoperitônio de 10mmHg e de l5mmHg de pressão intra-abdominal. Foram medidas a freqüência e débito cardíacos, pressão arterial média, pressão e diâmetro da artéria e veia femorais, velocidade do fluxo arterial e venoso femorais. Após a realização do pneumoperitônio foi encontrado aumento significativo na pressão e no diâmetro da veia femoral e diminuição significativa na velocidade do fluxo venoso femoral. A elevação da pressão venosa femoral e a diminuição da velocidade do fluxo venoso femoral foram mais intensas com o aumento da pressão intra-abdominal. Todos os parâmetros analisados retornaram aos valores iniciais após o esvaziamento do pneumoperitônio.

Massive retroperitoneal hemorrhage associated with femoral vein cannulation

The right external iliac artery was inadvertently punctured during attempted right femoral vein catheterization. Severe hypotension developed several minutes after the arterial puncture. Concurrently, a large right lower abdominal quadrant swelling (approximately 5 cm in diameter) became apparent. Laparoscopic observation of the retroperitoneal region immediately revealed massive retroperitoneal hemorrhage. Abdominal computerized tomographic scan indicated development of a huge (approximately 10 cm in the maximum diameter) retroperitoneal hematoma along the right psoas muscle from the level of the right external iliac vessels up to the level of the upper pole of the right kidney. Consideration of the anatomy of the "right" femoral and retroperitoneal vessels (ie, mediolateral relationship between the vein and artery) led us to conclude that the site for insertion of the needle was too proximal and the angle for advancement of the needle too low in our patient, allowing the needle to reach and injure the "incompressible" external iliac artery, thereby causing massive retroperitoneal hemorrhage. Although femoral vein catheterization has generally been considered a relatively safe method of intravenous access, a life-threatening serious complication can occur with the inappropriate technique used in our case.

Subcutaneous emphysema and pneumothorax during laparoscopy for ectopic pregnancy removal

We report a case of subcutaneous emphysema and pneumothorax during laparoscopic removal of ectopic pregnancy. Increases in airway pressures and end-tidal carbon dioxide, simultaneously with decrease of lung compliance, led quickly to diagnosis of pneumothorax. We recommend a careful monitoring of these variables during laparoscopic procedures. Carbon dioxide pneumothorax can occur even without pulmonary or pleural trauma.