Factors Involved in Gas Embolism after Laparoscopic Injury to Inferior Vena Cava

This study evaluated the incidence and factors involved in the occurrence of gas embolism after laparoscopic injuries. A 5-MHz transesophageal echocardiographic (TEE) probe was placed in 11 anesthetized pigs and used to examine the right cardiac chambers and pulmonary artery. A calibrated carbon dioxide analyzer continuously measured end-tidal carbon dioxide (ETCO₂). The ventilatory settings were adjusted to achieve a baseline ETCO₂ between 25 and 28 mm Hg. A blinded dose-response curve for TEE and ETCO₂ measurements were created by injecting 0.0007 to 1.5 mL/kg of CO₂ gas intravenously. Venotomies (N = 22) were created laparoscopically in the inferior vena cava (IVC) of the study animals. All TEE images were video-taped and correlated with laparoscopic events. Embolic episodes were classified by comparison with images recorded during the bolus studies. A variety of methods for obtaining hemostasis and repairing the venotomies were evaluated and their effects on gas embolism were studied. No emboli were noted when the venotomies were bleeding freely, the hole was directly occluded, or the proximal IVC was compressed. Marked embolism was seen with distal IVC occlusion or when there had been significant blood loss. In this situation, manipulation of the hole and higher intraperitoneal pressures led to higher degrees of embolization. No emboli were seen in an open control group except after significant bleeding. The TEE is the most sensitive method of detecting gas emboli; however, the majority of episodes are not clinically significant. Embolism of CO₂ occurs when central venous pressure is decreased by blood loss or distal compression. When significant venous bleeding occurs, intravascular volume should be maintained and the bleeding site should be directly occluded.