Fatal carbon dioxide embolism complicating attempted laparoscopic cholecystectomy--case report and literature review

Laparoscopic cholecystectomy has become the surgical procedure of choice for individuals with symptomatic gallbladder disease. The procedure has gained popularity among surgeons and patients because of inconspicuous abdominal incisions/scars, less postoperative pain, shorter hospitalization, and reduced medical costs. Bile duct, vascular, and gastrointestinal iatrogenic injuries are major complications. We describe the case of a 50-year-old woman who died of CO2 embolism during elective laparoscopic cholecystectomy for symptomatic cholelithiasis. With the patient under general anesthesia, a 1.5 cm incision was made just below the umbilicus, and a pneumoperitoneum was created by CO2 insufflation with a pneumoperitoneum (modified Veress) needle. Immediately, she experienced a cardiopulmonary arrest and could not be resuscitated. At autopsy, air bubbles were admixed with blood in the epicardial veins and leptomeningeal blood vessels. A triangular 0.1 cm perforation in the left common iliac vein had been created by the pneumoperitoneum needle. A pneumoperitoneum is required for laparoscopy and CO2 is the most commonly used gas. Carbon dioxide is highly soluble in blood and fairly innocuous to the peritoneum. Small amounts absorbed into the circulation cause slight increases in arterial and alveolar CO2 and in central venous pressure. When CO2 enters the venous circulation through iatrogenically opened vascular channels, catastrophic and potentially fatal hemodynamic and respiratory compromise may result.