Surgical emphysema as a cause of severe hypercapnia during laparoscopic surgery

Surgical emphysema is a well-recognised complication of laparoscopic surgery, but its impact on end-tidal carbon dioxide levels and carbon dioxide elimination is seldom reported and may not be fully appreciated by anaesthetists. Four cases are presented where extensive surgical emphysema occurred during laparoscopic surgery. The visual display of the anaesthetic record using the software program Monitor showed substantial rises in end-tidal carbon dioxide levels and allowed calculation of the carbon dioxide elimination, which increased two- to three-fold above normal levels. Having a visual record of carbon dioxide changes facilitated the recognition of surgical emphysema in three out of the four cases. Strategies such as estimating and tracking changes in carbon dioxide elimination from the minute ventilation and end-tidal carbon dioxide levels may assist in early identification, and palpating for surgical emphysema is recommended during laparoscopy if other causes of increased carbon dioxide levels are excluded.