Paradoxical Carbon Dioxide Embolism During Pneumoperitoneum in Laparoscopic Surgery for a Huge Renal Angiomyolipoma

Abstract

We present a case of paradoxical gas embolism during CO2 insufflation in laparoscopic nephrectomy for a huge renal angiomyolipoma. Paradoxical CO2 embolism in the left heart chambers without demonstrable intracardiac right-to-left shunt was detected by transesophageal echocardiography (TEE). The surgical procedure was stopped immediately, but the patient recovered with mild neurologic deficit. We speculate that rapid pneumoperitoneum introduction pushed CO2 into the abnormal vasculature of the angiomyolipoma, which communicates with the systemic vascular system, causing pseudoaneurysm formation. Follow-up abdominal computed tomography showed a new pseudoaneurysm inside the tumor. If intracardiac right-to-left shunt is excluded for the reason of paradoxical gas existence, there remains extracardiac right-to-left shunt, with transpulmonary passage of the venous emboli being the most likely mechanism. In fact, the cause of paradoxical gas embolism in this case remains unknown. Therefore, laparoscopic surgery for huge angiomyolipoma should be performed with extreme caution; an open procedure may be considered as an alternative.

Paradoxical carbon dioxide embolism during laparoscopic surgery without intracardiac right-to-left shunt: two case reports and a brief review of the literature

“…Furthermore, paradoxical CO 2 embolism in the systemic circulation has been reported during laparoscopic liver resection, 4 laparoscopic cholecystectomy, 5 gynecological laparoscopy, 6 and laparoscopic nephrectomy. 7 We herein present two cases of paradoxical CO 2 embolism during laparoscopic radical nephrectomy for renal cell carcinoma (Case 1) and laparoscopic hepatic left lateral lobectomy, hepatic radiofrequency ablation, and resection of a sigmoid tumor (Case 2). TEE detected CO 2 bubbles before the end-tidal CO 2 partial pressure (P ET CO 2 ) dropped.…”

Carbon Dioxide Embolism during Laparoscopic Surgery

“…Most reports, however, described significant decreases in ETCO 2 with clinical episodes of carbon dioxide embolism 6-8,23,44. A small transient rise in ETCO 2 follows larger boluses, probably caused by an increase in the carbon dioxide dissolved in the blood.…”

Transient Left-Sided Paralysis following Robotic-Assisted Laparoscopic Uteropexy

“…Systemic gas emboli are thought to be right to left shunting of venous gas embolism, either intracardiac due to patent foramen ovale (PFO) or extracardiac via transpulmonary air passage [ 14 , 15 ]. Huang et al [ 15 ] described a case report with presumed extracardiac paradoxical CO 2 embolism, which resulted in neurologic deficit and weakness of all four limbs. In this case TEE showed acute gas embolism in both left and right side of the heart with no embolism detected on CT of MRI of the brain.…”