title: Intra-abdominal fire due to insufflating oxygen instead of carbon dioxide during robot-assisted radical prostatectomy: case report and literature review.
abstract: We report the first case of intra-abdominal combustion involving the plastic covering of monopolar scissors secondary to use of incorrect gas (oxygen [O(2)] instead of carbon dioxide [CO(2)]) during robot-assisted laparoscopic radical prostatectomy (RALP). The insufflating system was connected to a provisional O(2) gate into the operating theater. A patient underwent RALP and extended pelvic lymph node dissection for localized prostate cancer, according to standard technique. Approximately 1.5 h after the start of surgery, flames arose from the scissor tips during monopolar coagulation. After extinguishing the fire, we promptly withdrew and changed instruments before recognizing and resolving the cause of the incident. The procedure was carried out without patient injury, and the postoperative period was uneventful.
authors.affiliation: Klinik für Urologie, Luzerner Kantonsspital, Lucerne, Switzerland.
authors.forename: Giovanni B
authors.initials: GB
authors.lastname: Di Pierro
authors.forename: Ivo
authors.initials: I
authors.lastname: Besmer
authors.forename: Lukas J
authors.initials: LJ
authors.lastname: Hefermehl
authors.forename: Josef
authors.initials: J
authors.lastname: Beatrice
authors.forename: Hansjörg
authors.initials: H
authors.lastname: Danuser
authors.forename: Jonas
authors.initials: J
authors.lastname: Beutler
authors.forename: Agostino
authors.initials: A
authors.lastname: Mattei
mesh_terms: D000005:Abdomen; D002245:Carbon Dioxide / Q000008:administration & dosage*; D005390:Fires; D006801:Humans; D007327:Insufflation / Q000379:methods*; D007431:Intraoperative Complications / Q000209:etiology*; D008297:Male; D019300:Medical Errors; D010100:Oxygen / Q000008:administration & dosage*; D011468:Prostatectomy / Q000379:methods; D012371:Robotics
chemical_list: D002245:Carbon Dioxide; D010100:Oxygen