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.