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Gas embolism during laparoscopic liver resection in a pig model: frequency and severity
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
2010 (English)In: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 105, no 3, 282-288 p.Article in journal (Refereed) Published
Abstract [en]

Background. Laparoscopic liver surgery is evolving rapidly. Carbon dioxide embolism is a potential complication. The aim of this work was to study the frequency and severity of gas embolism (GE) during laparoscopic liver lobe resection in a pig model and the resulting cardiovascular and respiratory changes. Methods. Fifteen anaesthetized piglets underwent laparoscopic left liver lobe resection. Haemodynamic and respiratory variables were monitored, including systemic and pulmonary arterial pressures, end-tidal CO2, and pulmonary dead space. Online blood gas monitoring and a transoesophageal echocardiography (TOE) were used. GE was graded semi-quantitatively as grade 0 (none), grade 1 (minor), or grade 2 (major), depending on the TOE results. Results. In 10 of 15 piglets, GE occurred. In total, 33 separate episodes of GE were recorded. All 13 episodes of grade 2 and three of grade 1 were serious enough to cause mainly respiratory, but also haemodynamic effects. Mostly, grade 1 GE caused only minor respiratory or haemodynamic changes. Most variables were affected during grade 2 GE; the most important were Pa-O2, Pa-CO2, end-tidal CO2, Vd/Vt, and mean pulmonary arterial pressure. Conclusions. GE occurred frequently during laparoscopic liver resection in this experimental study. Approximately half of the embolisms were serious enough to cause respiratory or haemodynamic disturbances or both. Pending further human studies, a combination of several monitoring techniques, with narrow limits for the alarm settings, will ensure correct interpretation of the complex physiological response to GE and reveal it early enough to alert the anaesthetist and the surgeon to the ongoing problem.

Place, publisher, year, edition, pages
2010. Vol. 105, no 3, 282-288 p.
Keyword [en]
embolism, air, liver, surgery, laparoscopic, swine
National Category
Medical and Health Sciences
URN: urn:nbn:se:uu:diva-134889DOI: 10.1093/bja/aeq159ISI: 000282074300006PubMedID: 20621927OAI: oai:DiVA.org:uu-134889DiVA: diva2:374093
Available from: 2010-12-02 Created: 2010-12-02 Last updated: 2015-06-08Bibliographically approved
In thesis
1. Gas Embolism in Laparoscopic Liver Surgery
Open this publication in new window or tab >>Gas Embolism in Laparoscopic Liver Surgery
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Laparoscopic liver surgery is complicated due to the structure of this organ with open sinusoids. A serious disadvantage is the risk of gas embolism (GE) due to CO2 pneumoperitoneum. CO2 can enter the vascular system through a wounded vein. A common opinion is that gas fluxes along a pressure gradient, e.g. CVP-intra abdominal pressure (IAP). The occurrence of GE could also be eased by entrainment, a ‘Venturi-like’ effect, due to cyclic differences in thoracic pressure and blood flow caused by mechanical ventilation at normal frequency.

The aims of these studies were to survey, in a porcine model, the influence on respiratory and haemodynamic variables by GE, to determine at what frequency, severity and duration GE occurs during laparoscopic liver resection (LLR) and whether there are methods to influence the occurrence or severity of GE.

Pulmonary and circulatory variables were monitored and measured as well as continuous blood gas monitoring. Transoesophageal echocardiogram was used to identify GE and, according to the amount of bubbles in the right outflow tract of the heart, GE was graded as 0, 1 and 2. Pneumoperitoneum was created by using CO2and IAP was set to 16 mm Hg.

A single bolus dose of CO2 influenced respiratory and haemodynamic variables for at least 4 h. During LLR GE occurred in 65-70% of the animals, of which the more serious caused negative influence on cardiopulmonary variables.

Elevated PEEP (15 cm H2O) increased CVP but GE occurred irrespective if CVP was lower than or exceeded IAP. In two last studies, a hepatic vein was cut and left open for 3 m before it was clipped. Interestingly, no signs of GE were seen despite an open vein and IAP > CVP in 8 of 20 animals. In the last study high frequency jet ventilation was used in order to minimise the risk of entrainment. The duration of GE was shortened.

The occurrence of GE seemed to be influenced by several different factors. The physiological reaction of a GE is impossible to predict for a specific patient, and depends among other factors on comorbidity, and amount, site and entrance rate of GE.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2012. 49 p.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 758
Gas embolism, laparoscopic liver, CVP, PEEP, high frequency jet ventilation, cardiopulmonary physiology, carbon dioxide
National Category
Basic Medicine
Research subject
Anaesthesiology and Intensive Care
urn:nbn:se:uu:diva-171797 (URN)978-91-554-8325-8 (ISBN)
Public defence
2012-05-11, Enghoffsalen, Akademiska Sjukhuset, Uppsala, 09:00 (English)
Available from: 2012-04-20 Created: 2012-03-27 Last updated: 2012-08-01Bibliographically approved

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