Paradoxical carbon dioxide embolism during pneumoperitoneum in laparoscopic surgery for a huge renal angiomyolipoma.
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.
Huang
Yu-Yin
YY
Department of Anesthesiology, Cheng-Hsin Rehabilitation Medical Center, Taipei, Taiwan, R.O.C.
Wu
Hsin-Lun
HL
Tsou
Mei-Yung
MY
Zong
Hsiao-Jen
HJ
Guo
Wan-You
WY
Chan
Kwok-Hon
KH
Ting
Chien-Kun
CK
D000368:Aged; D018207:Angiomyolipoma / Q000601:surgery*; D002245:Carbon Dioxide / Q000009:adverse effects*; D017548:Echocardiography, Transesophageal; D004618:Embolism, Air / Q000209:etiology*; D019320:Embolism, Paradoxical / Q000209:etiology*; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery*; D010535:Laparoscopy / Q000009:adverse effects*; D011028:Pneumoperitoneum, Artificial / Q000009:adverse effects*
D002245:Carbon Dioxide