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Li M, Yan B, Wang M, Zhu S, Kang X. A portent of catastrophic carbon dioxide embolism in laparoscopic hepatectomy: A case report. Medicine (Baltimore) 2024; 103:e38468. [PMID: 38875434 PMCID: PMC11175889 DOI: 10.1097/md.0000000000038468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
INTRODUCTION Laparoscopic hepatectomy (LH) poses a high risk of carbon dioxide embolism due to extensive hepatic transection, long surgery duration, and dissection of the large hepatic veins or vena cava. PATIENT CONCERNS A 65-year-old man was scheduled to undergo LH. Following intraperitoneal carbon dioxide (CO2) insufflation and hepatic portal occlusion, the patient developed severe hemodynamic collapse accompanied by a decrease in the pulse oxygen saturation (SpO2). DIAGNOSIS Although a decrease in end-tidal carbon dioxide (ETCO2) was not observed, CO2 embolism was still suspected because of the symptoms. INTERVENTIONS AND OUTCOMES The patient was successfully resuscitated after the immediate discontinuation of CO2 insufflation and inotrope administration. CO2 embolism must always be suspected during laparoscopic surgery whenever sudden hemodynamic collapse associated with decreased pulse oxygen saturation occurs, regardless of whether ETCO2 changes. Instant arterial blood gas analysis is imperative, and a significant difference between PaCO2 and ETCO2 is indicative of carbon dioxide embolism. CONCLUSION Instant arterial blood gas analysis is imperative, and a significant difference between PaCO2 and ETCO2 is indicative of carbon dioxide embolism.
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Affiliation(s)
- Mei Li
- Department of Anesthesiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Bing Yan
- Department of Anesthesiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
- Department of Anesthesiology, Haining People's Hospital, Haining, Zhejiang Province, China
| | - Mi Wang
- Department of Anesthesiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Shengmei Zhu
- Department of Anesthesiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xianhui Kang
- Department of Anesthesiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
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Robertson D, Sterke F, van Weteringen W, Arezzo A, Mintz Y, Horeman T. Escape of surgical smoke particles, comparing conventional and valveless trocar systems. Surg Endosc 2023; 37:8552-8561. [PMID: 37794124 PMCID: PMC10615925 DOI: 10.1007/s00464-023-10444-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/02/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND During minimal access surgery, surgical smoke is produced which can potentially be inhaled by the surgical team, leading to several health risks. This smoke can escape from the abdominal cavity into the operating room due to trocar leakage. The trocars and insufflator that are used during surgery influence gas leakage. Therefore, this study compares particle escape from a valveless (Conmed AirSeal iFS), and a conventional (Karl Storz Endoflator) system. MATERIALS AND METHODS Using an in vitro model, a conventional and a valveless trocar system were compared. A protocol that simulated various surgical phases was defined to assess the surgical conditions and particle leakage. Insufflation pressures and instrument diameters were varied as these are known to affect gas leakage. RESULTS The conventional trocar leaked during two distinct phases. Removal of the obturator caused a sudden release of particles. During instrument insertion, an average of 211 (IQR 111) particles per second escaped when using the 5 mm diameter instrument. With the 10 mm instrument, 50 (IQR 13) particles per second were measured. With the conventional trocar, a higher abdominal pressure increased particle leakage. The valveless trocar demonstrated a continuously high particle release during all phases. After the obturator was removed, particle escape increased sharply. Particle escape decreased to 1276 (IQR 580) particles per second for the 5 mm instrument insertion, and 1084 (IQR 630) particles per second for 10 mm instrument insertion. With the valveless trocar system, a higher insufflation pressure lowered particle escape. CONCLUSIONS This study shows that a valveless trocar system releases more particles into the operating room environment than a conventional trocar. During instrument insertion, the leakage through the valveless system is 6 to 20 times higher than the conventional system. With a valveless trocar, leakage decreases with increasing pressure. With both trocar types leakage depends on instrument diameter.
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Affiliation(s)
- Daniel Robertson
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands.
| | - Frank Sterke
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Willem van Weteringen
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Anesthesiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Yoav Mintz
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Tim Horeman
- Department of Biomechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands
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Shimizu K, Usuda M, Kakizaki Y, Narita T, Suzuki O, Fukuoka K. Cerebral infarction by paradoxical gas embolism detected after laparoscopic partial hepatectomy with an insufflation management system: a case report. Surg Case Rep 2023; 9:34. [PMID: 36855003 PMCID: PMC9975143 DOI: 10.1186/s40792-023-01611-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/15/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Laparoscopic surgery has reduced surgical morbidity and postoperative duration of hospital stay. Gas embolism is commonly known as a risk factor for all laparoscopic procedures. We report a case of severe cerebral infarction presumably caused by paradoxical CO2 embolism in laparoscopic partial hepatectomy with an insufflation management system. CASE PRESENTATION A male in his 60 s was diagnosed with recurrence of liver metastasis in the right hepatic lobe after laparoscopic lower anterior resection for rectal cancer. We performed laparoscopic partial hepatectomy with an AirSeal® under 10 mmHg of intra-abdominal pressure. During the surgery, the patient's end-tidal CO2 and percutaneous oxygen saturation dropped from approximately 40-20 mmHg and 100-90%, respectively, while the heart rate increased from 60 to 120 beats/min; his blood pressure remained stable. Postoperatively, the patient developed right hemiplegia and aphasia. Brain magnetic resonance imaging showed cerebral infarction in the broad area of the left cerebral cortex. Thereafter, transesophageal echocardiography revealed a patent foramen ovale, suggesting cerebral infarction due to paradoxical gas embolism. CONCLUSIONS A patent foramen ovale is found in approximately 15-20% of healthy individuals. While gas embolism is a rare complication of laparoscopic surgery, cerebral infarction must be considered a possible complication even if the intra-abdominal pressure is constant under 10 mmHg with an insufflation management system.
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Affiliation(s)
- Kenji Shimizu
- Departments of Gastroenterological Surgery, Iwate Prefectural Central Hospital Morioka, Iwate, Japan.
| | - Masahiro Usuda
- grid.414862.dDepartments of Gastroenterological Surgery, Iwate Prefectural Central Hospital Morioka, Iwate, Japan
| | - Yuta Kakizaki
- grid.414862.dDepartments of Gastroenterological Surgery, Iwate Prefectural Central Hospital Morioka, Iwate, Japan
| | - Tomohiro Narita
- grid.414862.dDepartments of Gastroenterological Surgery, Iwate Prefectural Central Hospital Morioka, Iwate, Japan
| | - On Suzuki
- grid.414862.dDepartments of Gastroenterological Surgery, Iwate Prefectural Central Hospital Morioka, Iwate, Japan
| | - Kengo Fukuoka
- grid.414862.dDepartments of Gastroenterological Surgery, Iwate Prefectural Central Hospital Morioka, Iwate, Japan
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Carpenter EL, Flinn AN, Schechtman DW, Adams AM, Clifton GT, Krell RW, Alseidi AA, Vreeland TJ, Schaffner TJ. Iatrogenic Inferior Vena Cava Injury in the Reoperative Foregut: a Technique for Minimally Invasive Repair. Obes Surg 2023; 33:1307-1308. [PMID: 36715967 DOI: 10.1007/s11695-023-06473-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 12/10/2022] [Accepted: 01/18/2023] [Indexed: 01/31/2023]
Affiliation(s)
- Elizabeth L Carpenter
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr, San Antonio, TX, 78219, USA.
| | - Ashley N Flinn
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr, San Antonio, TX, 78219, USA
| | - David W Schechtman
- University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Alexanda M Adams
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr, San Antonio, TX, 78219, USA
| | - Guy T Clifton
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr, San Antonio, TX, 78219, USA
| | - Robert W Krell
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr, San Antonio, TX, 78219, USA
| | - Adnan A Alseidi
- University of California, 400 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Timothy J Vreeland
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr, San Antonio, TX, 78219, USA
| | - Timothy J Schaffner
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brooke Dr, San Antonio, TX, 78219, USA.,Bon Secours Mercy Health, 3636 High St, Portsmouth, VA, 23707, USA
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Levine D, Petroski GF, Haertling T, Beaudoin T. Electrostatic Precipitation in Low Pressure Laparoscopic Hysterectomy and Myomectomy. JSLS 2020; 24:e2020.00051. [PMID: 33100818 PMCID: PMC7550014 DOI: 10.4293/jsls.2020.00051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The purpose of this study was to evaluate the impact of using electrostatic precipitation to manage the surgical plume during low pressure laparoscopic gynecologic procedures. METHODS This was a prospective, blinded, randomized controlled study of women with a clinical indication for laparoscopic hysterectomy (n = 30) or myomectomy (n = 5). Patients were randomized to either use electrostatic precipitation (EP) during the procedure, or not (No EP, hysterectomy group only). RESULTS Low pressure surgery could be undertaken in 87% of hysterectomy cases (13/15) when using EP to manage the surgical plume, compared to only 53% (8/15) in the No EP group. Overall average rating of the visual field was excellent with EP vs fair for No EP. Average CO2 consumption was reduced by 29% when using EP (16.7L vs 23.5L, p = 0.152). The average number of procedural pauses to vent smoke was lower with EP than the No EP group (1.5 per case vs. 3.7 per case, p = 0.005). Average procedure duration for the EP vs No EP group was 40.5 min vs. 46.9 min (p = 0.987). There were no measurable differences between groups for body temperature, end-tidal CO2, and discharge pain scores. In myomectomy, all five cases could be performed at low pressure, with an excellent visual field rating. CONCLUSION Electrostatic precipitation enhances low pressure laparoscopic hysterectomy and myomectomy. This was achieved by minimizing interruptions to surgery and exchange of CO2; providing a clear visual field throughout the procedure; and eliminating surgical smoke at the site of origin.
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Affiliation(s)
- David Levine
- Department of Obstetrics and Gynecology, Mercy Hospital, 621 S. New Ballas Rd, St. Louis, Missouri
| | - Gregory F Petroski
- Biostatistics & Research Design Unit, University of Missouri - Columbia School of Medicine, 182C Galena Hall, Columbia, Missouri
| | - Tracy Haertling
- Mercy Research, 3231 S. National Ave., Ste 210, Springfield, Missouri
| | - Teresa Beaudoin
- Mercy Research, 615 S. New Ballas Rd, Ste 2010, St. Louis, Missouri
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Fromer IR, Horvath B, Prielipp RC, Kloesel B. Vascular Air Emboli During the Perioperative Period. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00407-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Dalli J, Khan MF, Nolan K, Cahill RA. Laparoscopic pneumoperitoneum escape and contamination during surgery using the Airseal Insufflation System - a video vignette. Colorectal Dis 2020; 22:1029-1030. [PMID: 32644263 PMCID: PMC7362043 DOI: 10.1111/codi.15255] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 06/25/2020] [Indexed: 02/08/2023]
Affiliation(s)
- J. Dalli
- UCD Centre for Precision SurgerySchool of MedicineUniversity College DublinDublinIreland,Department of SurgeryMater Misericordiae University HospitalDublinIreland
| | - M. F. Khan
- UCD Centre for Precision SurgerySchool of MedicineUniversity College DublinDublinIreland,Department of SurgeryMater Misericordiae University HospitalDublinIreland
| | - K. Nolan
- School of Mechanical and Material EngineeringCollege of Engineering and ArchitectureUniversity College DublinDublinIreland
| | - Ronan A Cahill
- UCD Centre for Precision SurgerySchool of MedicineUniversity College DublinDublinIreland,Department of SurgeryMater Misericordiae University HospitalDublinIreland
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Weenink RP, Kloosterman M, Hompes R, Zondervan PJ, Beerlage HP, Tanis PJ, van Hulst RA. The AirSeal® insufflation device can entrain room air during routine operation. Tech Coloproctol 2020; 24:1077-1082. [PMID: 32734478 PMCID: PMC7522110 DOI: 10.1007/s10151-020-02291-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/02/2020] [Indexed: 11/29/2022]
Abstract
Background Surgical procedures that use insufflation carry a risk of gas embolism, which is considered relatively harmless because of the high solubility of carbon dioxide. However, an in vitro study suggested that valveless insufflation devices may entrain non-medical room air into the surgical cavity. Our aim was to verify if this occurs in actual surgical procedures. Methods The oxygen percentage in the pneumoperitoneum or pneumorectum/pneumopelvis of eight patients operated with use of the AirSeal® was continuously measured, to determine the percentage of air in the total volume of the surgical cavity. Results Basal air percentage in the surgical cavity was 0–5%. During suctioning from the operative field air percentage increased to 45–65%. Conclusions The AirSeal® valveless insufflation device maintains optimal distension of the surgical cavity not only by insufflating carbon dioxide, but also by entraining room air, especially during suctioning from the operative field. This may theoretically lead to air embolism in patients operated on with this device.
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Affiliation(s)
- R P Weenink
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Kloosterman
- Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - P J Zondervan
- Department of Urology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H P Beerlage
- Department of Urology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - R A van Hulst
- Department of Hyperbaric Medicine and Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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