Carbon Dioxide Embolism Following Veress Needle Insertion Into the Liver During Laparoscopic Adrenalectomy

Although rare, complications can arise during the establishment of pneumoperitoneum during laparoscopic surgery. These include injury to blood vessels, hollow viscera, solid organs, and CO2 embolism. We report a case of trauma to the liver following the insertion of a Veress needle causing CO2 embolism during laparoscopic adrenalectomy. Opening pressures on insertion were high. Respiratory and cardiovascular changes alerted the anesthesiologists to the possibility of CO2 embolism. The patient was treated with inotropic drugs, placed in Durant’s position, and the operation was aborted. Ultrasound demonstrated gas bubbles within the liver parenchyma and the heart chambers. The patient was transferred to the surgical intensive care unit where she experienced a grand mal seizure. She was later taken to a nearby hospital for hyperbaric oxygen therapy during which she suffered 3 additional seizures. She had subsequent resolution of all neurological symptoms. The first entry into the peritoneum deserves the full attention of the operating room team, because this is when most CO2 embolisms occur. The team should be prepared to take immediate action on suspicion of embolism. Gas embolism can occur not only by direct cannulation of blood vessels, but also by injury to solid organs, especially the liver. All overweight patients should be suspected of having hepatomegaly and the location of initial entry into the peritoneum should shift accordingly. In selected patients, one should use a direct visualization approach, because this approach has fewer complications and they are more readily identified.