Carbon dioxide embolism in a 3-week-old neonate during laparoscopic pyloromyotomy: a case report

Gas Embolism in Pediatric Minimally Invasive Surgery: Should It Be a Concern?

Introduction: Gas embolism can occur during minimally invasive surgical procedures. Its incidence and implications in infants and children are not clear. The objective of this study is to identify gas embolism with transthoracic echocardiography and its consequences in pediatric laparoscopic appendectomy. Materials and Methods: This is a descriptive observational study including children undergoing laparoscopic appendectomy. We performed transthoracic echocardiography during surgery and collected data on intraoperative hemodynamic and respiratory parameters. Results: To date, we have included 10 patients in whom intraoperative transthoracic echocardiography revealed a 50% incidence of gas embolism. All episodes of embolism were grade I or II, and the patients remained asymptomatic. The hemodynamic and respiratory parameters varied slightly during the pneumoperitoneum. Conclusions: Episodes of gas embolism in pediatric laparoscopic appendectomy appeared in up to 50% of patients. Although they were subclinical, we should be aware of the risk of serious events and take measures to maximize safety in pediatric minimally invasive surgery.

Rates of Air Embolism in Pediatric Patients Undergoing Surgical Procedures of the Peritoneum

Background: Air embolism during laparoscopic surgery is a rare but feared complication in the pediatric population. The objective of this study was to identify rates of air embolus in pediatric patients during hospitalization for laparoscopic or open surgical procedures of the peritoneal cavity. Materials and Methods: Patients 0-18 years old within the Pediatric Health Information System who underwent a predefined, common inpatient laparoscopic or open surgical procedure involving the peritoneal cavity from 2015 to 2020 were studied. International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for air embolism were then searched among patients during the same admission. Firth logistic regression was used to compare rates of air embolism in open and laparoscopic cohorts and in patients >1 and ≤1 year. Results: Unadjusted rates of air embolism were higher in patients undergoing open compared with laparoscopic surgery (open: 9/45,080; 20.0/100,000 patients versus laparoscopic: 3/101,892; 2.9/100,000 patients). In patients ≤1 year (45,726), 2 patients undergoing open surgery (2/1,031; 9.5/100,000 patients) and all 3 patients undergoing laparoscopic surgery had an air embolism diagnosis (3/22,329; 13.4/100,000 patients). For laparoscopic surgery, a suggested lower relative risk (RR) of air embolism was demonstrated for children >1 year compared with children ≤1 year (RR: 0.05, P = .05). Conclusion: Air embolism associated with common pediatric surgical procedures of the peritoneum is rare and patients undergoing laparoscopic and open surgery have similar risks for air embolism. Although rare, the risk should be considered during surgical planning and abdominal access, especially in children ≤1 year old.

Guidelines of the Italian Society of Videosurgery (SIVI) in Infancy for the minimally invasive treatment of Hypertrophic Pyloric Stenosis in neonates and infants

The most appropriate treatment for the infantile Hypertrophic Pyloric Stenosis (HPS) is still debated. The non-surgical conservative treatment with oral or intravenous administration of atropine does not enjoy a widespread appreciation for several factors (...).

Umbilical access in laparoscopic surgery in infants less than 3 months of age: A survey of the American Pediatric Surgical Association

PURPOSE

Laparoscopy is commonplace in pediatric surgery. Abdominal access via the umbilicus may present a unique challenge in neonates and young infants predisposing them to complications. We hypothesized that these complications may occur more than described in the literature.

METHODS

Members of the American Pediatric Surgical Association (APSA) were anonymously surveyed in February of 2018 via REDCap™ regarding technique of umbilical access in infants less than 3 months of age and complications experienced during umbilical access. Approval was obtained from the IRB and the APSA Outcomes and Evidence-based Practice Committee.

RESULTS

The response rate was 31.3% (329/1050). 62.3% of respondents performed 21 or greater neonatal laparoscopic procedures annually. 34 of 322 respondents reported a direct complication from umbilical access for laparoscopy in this age group (10.6%). Surgeons described 37 specific cases with complications related to umbilical access, with laparoscopic pyloromyotomy making up 47.2% (17/36). CO₂ embolism was the most common complication; 15.4% of surgeons reported not knowing about the possibility of CO₂ embolism. 41% of surgeons confirm intraabdominal placement of the umbilical trocar prior to insufflation. There was no association between any complication and where the umbilical trocar was placed (above/below/through umbilicus) or placement technique in patients with no umbilical cord stump. There may be an association between complication and where the umbilicus is entered in patients with an umbilical cord stump still in place (p = 0.013).

CONCLUSIONS

Umbilical access for laparoscopy in neonates and infants less than 3 months of age can present a unique challenge and result in significant complications. All techniques and methods had complications. Surgeons should be aware of these risks and be prepared to manage them emergently if they arise.

LEVEL OF EVIDENCE

V, expert opinion.

Are Cardiac Anomalies and Persistent Fetal Circulation a Risk Factor for Cardiovascular Events During Minimally Invasive Surgery in Neonates?

Introduction: Minimally invasive surgery (MIS) in neonates is progressively performed. The aim of this study was to evaluate the risk for cardiovascular events during endoscopic surgery in neonates and to analyze the influence of persistent fetal circulation and/or cardiac anomalies. Materials and Methods: This is a retrospective single institution study including all neonates undergoing MIS. The charts were reviewed for intraoperative cardiovascular events and operative procedure was performed. Special attention was paid to cardiac anomalies and persistent fetal circulation. In addition, a review of the literature was performed. Results: Between January 2004 and December 2012, 108 neonates underwent MIS at our institution. Laparoscopic surgery was performed in 91 (84.3%) and thoracoscopy in 17 (15.7%) babies. None of these 108 patients developed a cardiovascular event during endoscopic surgery (0.0%). Persistent fetal circulation and/or cardiac anomalies were evaluated in 50 of 108 (46.3%) neonates. In the additionally performed review of the literature, four single case reports were identified. All 4 authors published a major cardiovascular event during laparoscopic surgery in neonates. In all 4 patients, gas embolism through a patent umbilical vein was assumed to be responsible for the cardiovascular event. Conclusions: In our opinion, the main risk factor for the development of a major cardiovascular event during MIS in neonates is vascular injury of a persistent umbilical vein. Persistent fetal circulation and/or cardiac anomalies seem to be less important. In case of injury of a persistent umbilical vein, the risk of gas embolism has to be respected and conversion to the open approach has to be considered.

Extracorporeal cardiopulmonary resuscitation in a neonate after air embolism during insufflation for laparoscopic peritoneal dialysis catheter placement

Laparoscopy is increasingly utilized in neonatal surgery with safe and effective outcomes. Air embolism from insufflation for pneumoperitoneum is a rare but known risk of laparoscopy. Here we present a rare case of air embolism during insufflation for laparoscopic peritoneal dialysis catheter placement treated with extracorporeal cardiopulmonary resuscitation.

Advanced minimal access surgery in infants weighing less than 3kg: A single center experience

BACKGROUND

Minimal access surgery (MAS) has gained popularity in infants less than 5kg, however, significant challenges still arise in very low weight infants.

STUDY DESIGN

A retrospective chart review was performed to identify all infants weighing less than 3kg who underwent an advanced MAS or equivalent open procedure from 2009 to 2016. Advanced case types included Nissen fundoplication, duodenal atresia repair, Ladd procedure, congenital diaphragmatic hernia repair, esophageal atresia/tracheoesophageal fistula repair, diaphragmatic plication, and pyloric atresia repair. A comparative analysis was performed between the MAS and open cohorts.

RESULTS

A total of 45 advanced MAS cases and 17 open cases met the inclusion criteria. Gestational age and age at operation were similar between the cohorts, while infants who underwent open procedures had significantly lower weight at operation (p=0.003). There were no deaths within 30days related to surgery in either group. Only 3 MAS cases required unintended conversion to open. There were 2 (4.4%) postoperative complications related to surgery in the MAS cohort and 2 (11.8%) in the open cohort.

CONCLUSION

Advanced MAS may be performed in infants weighing less than 3kg with low mortality, acceptable rates of conversion, and similar rates of complications as open procedures.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level III.

Pneumoperitoneum for neonatal laparoscopy: how safe is it?

We present the case of a 3 day old term neonate who experienced a cardiopulmonary arrest during creation of pneumoperitoneum for laparoscopic repair of duodenal atresia. The arrest was thought likely to have occurred as a result of a gas embolism. We discuss the features of the neonatal circulation which may predispose neonates to embolic phenomena during laparoscopic procedures, and the potential benefit of priming the insufflation apparatus with carbon dioxide. The possibility of gas embolism should be considered when contemplating laparoscopic surgery in this patient group.

Minimally invasive surgery in the neonate

The advent of minimally invasive surgical techniques in the neonate has been delayed due to the limited working space and the unique physiology of the newborn. In the last decade, with the introduction of new instruments and techniques, many of the initial problems have been solved making minimally invasive surgery feasible for a variety of indications in the neonate and a favored approach in specialized centers around the world. Although an increasing number of reports document the feasibility of this exciting technique, data demonstrating its benefit compared to conventional surgery is limited. This review focuses on recent developments in minimally invasive surgery in neonates and the evidence for its use.

Carbon dioxide embolism during laparoscopic sleeve gastrectomy

Bariatric restrictive and malabsorptive operations are being carried out in most countries laparoscopically. Carbon dioxide or gas embolism has never been reported in obese patients undergoing bariatric surgery. We report a case of carbon dioxide embolism during laparoscopic sleeve gastrectomy (LSG) in a young super obese female patient. Early diagnosis and successful management of this complication are discussed. An 18-year-old super obese female patient with enlarged fatty liver underwent LSG under general anesthesia. During initial intra-peritoneal insufflation with CO(2) at high flows through upper left quadrant of the abdomen, she had precipitous fall of end-tidal CO(2) and SaO(2) % accompanied with tachycardia. Early suspicion led to stoppage of further insufflation. Clinical parameters were stabilized after almost 30 min, while the blood gas analysis was restored to normal levels after 1 h. The area of gas entrainment on the damaged liver was recognized by the surgeon and sealed and the surgery was successfully carried out uneventfully. Like any other laparoscopic surgery, carbon dioxide embolism can occur during bariatric laparoscopic surgery also. Caution should be exercised when Veress needle is inserted through upper left quadrant of the abdomen in patients with enlarged liver. A high degree of suspicion and prompt collaboration between the surgeon and anesthetist can lead to complete recovery from this potentially fatal complication.

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.