Immediate management
The key to managing this possibly life-threatening complications lies in
making the correct diagnosis. Vascular injury, after identified, should
start with leaving the insufflation device in place. The Veress needle,
or other insufflating device, can serve to occlude the damaged vessel
and removing the instrument may allow blood to rapidly leave the
vasculature and even make the rent in the vessel larger. An exploratory
laparotomy can then be performed where the damaged vessel is identified,
the insufflation instrument removed under direct visualization and the
vessel repaired. It would be advantageous at this point to recruit the
assistance of vascular surgery or other specialists well practiced in
large vessel repair. This event should be immediately communicated to
the anesthesia team who can begin volume resuscitation, replacement of
blood products and even possible pressor support to maintain perfusion
and avoid further hemorrhagic shock. Consideration should also be made
for aortic cross-clamping or using an aortic occlusion balloon, both of
which are routinely used in aortic surgery by vascular surgeons for
hemorrhage control. Care should be taken to place the clamp as distal as
possible, to avoid renal and gastrointestinal tract ischemia, and to
avoid clamping the inferior vena cava.
The management of carbon dioxide embolism is significantly different and
therefore the need to make the correct diagnosis. The mainstay of carbon
dioxide embolism treatment is to stop insufflating gas into the patient.
The gas should be turned off and the pneumoperitoneum released. All of
these actions will decrease more carbon dioxide from entering the blood
stream. Again, this should be communicated to the anesthesia team who
can also help with the diagnosis (end tidal carbon dioxide readings and
mill-wheel murmur). The anesthesiologist can then hyperventilate the
patient to remove the carbon dioxide and position the patient on their
left side to trap carbon dioxide bubbles in the upper right atrium and
away from the pulmonary vasculature. In extreme cases, a central venous
line can be placed and gas bubbles removed from the right heart, though
typically by the time the line is placed the carbon dioxide has already
been absorbed: this is most helpful in patients with indwelling central
venous catheters. Hyperbaric therapy has been used to treat cerebral gas
emboli which arrived in the brain by a patent foramen ovale (paradoxical
emboli), an uncommon sequela of this uncommon condition.