Akihiko Oshita, MD, PhD, Masahide Shinzawa, MD, PhD, Masaru Sasaki, MD, PhD, Takashi Kumada, MD, Takuro Yamaguchi, MD, Hiroyuki Taogoshi, MD, Yasushi Kato, MD, Hiroyuki Nakamura, MD, PhD, Mikihiro Kanou, MD, Mohei Kouyama, MD, PhD, Yuji Imamura, MD, PhD, Masakazu Nakao, MD, PhD, Astushi Nakamitsu, MD, PhD
JA Hiroshima General Hospital
Introduction: Since many operative instruments including energy devices and endostaplers have been developed, hepato-biliary-pancreatic surgeons could get to perform laparoscopic liver resection more safely and easily. In transection of hepatic parenchyma, not only techniques and instruments including portal triad occlusion, precoagulation, and endostaplers but also high pressure of a pneumoperitoneum are used to control bleeding. However, the risk of high pressure of a pneumoperitoneum is not well debated. One of the risks is carbon dioxide (CO2) gas embolism. The authors would like to underline the usefulness of right atrium monitoring with transesophageal echocardiography (TEE) during pure laparoscopic liver resection to prevent crucial CO2 gas embolism.
Case: A 65-year-old male with no history of cardiopulmonary problems or veno-occlusive disease was referred for the treatment of a solitary hepatocellular carcinoma of 1.8 cm in diameter, located in segment 4, associated with alcoholic and HBV/HCV related liver cirrhosis. Laparoscopic partial hepatectomy was indicated because of the limited functional hepatic reserve. A pure laparoscopic liver resection was performed under 8 mmHg of the intraperitoneal pressure of a CO2 pneumoperitoneum. Liver parenchymal transection was performed using cavitron ultrasonic surgical aspirator system and saline-coupled bipolar electrocautery for hemostasis. During liver parenchymal transection, the pressure of a CO2 pneumoperitoneum was raised up to 12 mmHg to control bleeding from hepatic veins. When a tributary of middle hepatic vein (MHV) was damaged, TEE showed remarkably increased bubbles in the right atrium consequently. Immediately, pulse oximetric saturation (SpO2) dramatically went down to 87% under fraction of inspired oxygen of 0.46, while blood pressure and the other vital signs were stable. Since an anesthesiologist told surgeons that TEE showed CO2 gas embolism, compression hemostasis was performed. Then, bubbles were completely disappeared, resulting in the improvement of SpO2. After pure laparoscopic liver resection was completed with compression hemostasis, hybrid conversion was performed for safe hemostasis.
Conclusion: Right atrium monitoring with TEE could avoid crucial CO2 gas embolism in pure laparoscopic liver resection.
Session: Poster Presentation
Program Number: P619