Case Report
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Mar 26, 2022; 10(9): 2908-2915
Published online Mar 26, 2022. doi: 10.12998/wjcc.v10.i9.2908
Paradoxical carbon dioxide embolism during laparoscopic hepatectomy without intracardiac shunt: A case report
Soeun Jeon, Jeong-Min Hong, Hyeon Jeong Lee, Yesul Kim, Hyunjong Kang, Boo-young Hwang, Dowon Lee, Young-hoon Jung
Soeun Jeon, Jeong-Min Hong, Hyeon Jeong Lee, Yesul Kim, Hyunjong Kang, Boo-young Hwang, Dowon Lee, Young-hoon Jung, Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Busan 49241, South Korea
Soeun Jeon, Jeong-Min Hong, Hyeon Jeong Lee, Boo-young Hwang, Dowon Lee, Young-hoon Jung, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
Author contributions: Jeon S and Hong JM designed the study; Jeon S, Hong JM, and Lee HJ drafted the manuscript; Kim Y, Kang H, and Jung Y collected data and pictures; Jeon S, Hong JM, Lee HJ, Hwang B, and Lee D reviewed the literature and edited the manuscript; all authors agreed to be accountable for all aspects of the work, and all authors issued final approval for the version to be submitted.
Supported by Clinical Research Grant from Pusan National University Hospital in 2020.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Jeong-Min Hong, MD, PhD, Assistant Professor, Doctor, Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Busan 49241, South Korea. ccarrot@pusan.ac.kr
Received: October 5, 2021
Peer-review started: October 5, 2021
First decision: December 2, 2021
Revised: December 15, 2021
Accepted: February 20, 2022
Article in press: February 20, 2022
Published online: March 26, 2022
Processing time: 168 Days and 11.8 Hours
Abstract
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.

Keywords: Carbon dioxide; Embolism; Laparoscopy; Pneumoperitoneum; Transesophageal echocardiography; Case report

Core Tip: CO2 embolism is a rare but potentially life-threatening complication of laparoscopic surgery. In particular, paradoxical CO2 embolisms are highly associated with postoperative neurologic deficits. We report a case of paradoxical CO2 embolism identified using transesophageal echocardiography (TEE) during laparoscopic hepatectomy even though the patient did not have an intracardiac shunt. Generally, EtCO2 monitoring is a sensitive method for detecting gas embolism, but it is difficult to identify the extent or detailed status, such as paradoxical embolism. Intraoperative TEE can help quickly identify the presence and extent of CO2 embolism, which will help provide appropriate treatment and predicting postoperative complications.