Cardiac Arrest due to Carbon Dioxide Embolism During Laparoscopic Gynecologic Surgery of a Patient with Previous Abdominal Surgery: A Case Report

Catastrophic carbon dioxide (CO2) embolism is a rare, but potentially life-threatening, the complication of laparoscopic gynecologic surgery. We report the case of a healthy 53-year-old woman who developed CO2 embolism and cardiac arrest during laparoscopic surgery. She had a history of two cesarean sections and had extensive peritoneal adhesions. After placement of the trocar and insufflation of CO2, end-tidal CO2 dropped from 35 to 15 mm Hg, and the patient had a cardiovascular collapse. In this patient, CO2 embolism was diagnosed on the basis of a sudden decrease in end-tidal CO2, hypotension, and hypoxemia. The patient was managed quickly and aggressively. The patient recovered completely following the treatment for CO2 embolism, with no cardiopulmonary or neurological sequelae. There is an increased risk of catastrophic CO2 embolism during laparoscopic gynecologic surgery in patients with previous abdominal surgery. Therefore, the surgeon and anesthesiologist should remain vigilant to promote early detection of CO2 embolism.

Conservative management of the colonic gallstone

A 74-year-old woman presents with a 7-day history of increasing lower abdominal pains and reduced bowel movements; resulting in absolute constipation.Twenty-four hours prior to admission she also had symptoms of nauseous and significant abdominal distention. Her past medical history included; diverticulitis, type 2 diabetes, hypercholesterolemia, an ultrasound scan in 2005 confirming gallstones, but no previous abdominal surgery.She was initially treated for bowel obstruction and a CT arranged. CT showed a 4.5 cm gallstone in mid-sigmoid colon and a cholecystocolonic fistula. She was booked for colonoscopy±laparotomy, but on the morning of her planned procedure she repeatedly opened her bowels. Subsequent colonoscopy was negative and repeat CT confirmed the stone was no longer within the gastrointestinal tract.

Evolution and trends in the adoption of laparoscopic liver resection in Singapore: Analysis of 300 cases

ABSTRACT Introduction: The introduction of laparoscopic surgery has changed abdominal surgery. We evaluated the evolution and changing trends associated with adoption of laparoscopic liver resection (LLR) and the experience of a surgeon without prior LLR experience. Methods: A retrospective review of 310 patients who underwent LLR performed by a single surgeon from 2011 to 2020 was conducted. Exclusion criteria were patients who underwent laparoscopic liver surgeries such as excision biopsy, local ablation, drainage of abscesses and deroofing of liver cysts. There were 300 cases and the cohort was divided into 5 groups of 60 patients. Results: There were 288 patients who underwent a totally minimally invasive approach, including 28 robotic-assisted procedures. Open conversion occurred for 13 (4.3%) patients; the conversion rate decreased significantly from 10% in the initial period to 3.3% subsequently. There were 83 (27.7%) major resections and 131 (43.7%) resections were performed for tumours in the difficult posterosuperior location. There were 152 (50.7%) patients with previous abdominal surgery, including 52 (17.3%) repeat liver resections for recurrent tumours, and 60 patients had other concomitant operations. According to the Iwate criteria, 135 (44.7%) were graded as high/expert difficulty. Major morbidity (>grade 3a) occurred in 12 (4.0%) patients and there was no 30-day mortality. Comparison across the 5 patient groups demonstrated a significant trend towards older patients, higher American Society of Anesthesiologists (ASA) score, increasing frequency of LLR with previous abdominal surgery, increasing frequency of portal hypertension and huge tumours, decreasing blood loss and decreasing transfusion rate across the study period. Surgeon experience (≤60 cases) and Institut Mutualiste Montsouris (IMM) high grade resections were independent predictors of open conversion. Open conversion was associated with worse perioperative outcomes such as increased blood loss, transfusion rate, morbidity and length of stay. Conclusion: LLR can be safely adopted for resections of all difficulty grades, including major resections and for tumours located in the difficult posterosuperior segments, with a low open conversion rate. Keywords: Laparoscopic hepatectomy, laparoscopic liver resection, robotic hepatectomy, robotic liver resection, Singapore

EP.TH.915An Audit of BAUS Guidelines and Complications of Suprapubic Catheter Insertion

Introduction The National Patient Safety Agency (NPSA) noted between September 2005 to June 2009, 259 incidents relating to suprapubic catheter (SPC) insertion were reported. 9 of these were bowel perforations. BAUS produced guidelines for SPC insertion which included recommending open or ultrasound guided insertion of SPCs in patients with previous lower abdominal surgery. The aim of this audit was to assess compliance with BAUS guidelines and complications following SPC insertion. Methods All patients who had a SPC inserted in theatre at this District General Hospital (DGH) between October 2012 to October 2019 were identified. Patient demographics, ASA grade, co-morbidities, previous abdominal surgery and complications were recorded. Results A total of 154 patients (59.1% male; 40.3% female) were identified. Mean age was 65 and mode ASA was 3. 21 (13.6%) of patients had previous lower abdominal surgery. Of these 2 (10%) had ultrasound guided insertion, 3 (14%) were open, 11 (52%) had cystoscopy guided insertion alone and for 5 (24%) the method was unknown. 4 (2.6%) of patients had a bowel injury following SPC insertion. Discussion At this DGH there was poor compliance with BAUS guidelines with a significant number of patients with lower abdominal surgery not having open or ultrasound guided insertion of SPC. 2.6% of patients had a bowel injury, however none of these had previous lower abdominal surgery. For these patients BAUS guidelines were adhered to, but bowel injury was not prevented. We therefore recommend the consideration of image guided insertion of SPCs in all patients where possible.

Pre-operative Prediction of Difficult Laparoscopic Cholecystectomy

Aim: To evaluate the factors for prediction of difficult laparoscopic cholecystectomy preoperatively. Methods: A Prospective Observational Study conducted at Surgical Unit II, Ghulam Muhammad Mahar Medical College Hospital Sukkur, from February 2020 to January 2021. Data was collected for 580 patients. All the patients fulfilling inclusion criteria were evaluated with following factors: age, gender, BMI, h/o previous GB disease, comorbids, h/o previous abdominal surgery, tender RHC, palpable gallbladder, ultrasonographic findings of gall bladder wall thickness, pericholecystic fluid collection & stone impaction at neck of gall bladder. Patients were assumed to be difficult on presence of one or more of above mentioned risk factors .laparoscopic cholecystectomy was performed by an experienced laparocopic surgeon. Peroperative findings and operative time was noted. Cases were considered difficult if operative time was >60 minutes or if the case was converted to open. All the information was recorded on predesigned proforma. Results: Age ranged from 23 to 70 years (mean age = 46.37 years). 456 patients were female while 124 patients were male. Majority of patients in our study (n=390) had normal BMI(BMI=18.5-24.9)and next majority (n=132) belonged to overweight group(BMI=25-29.9) . On inquiry, 93 patients had history of previous gall bladder disease in form of cholecystitis. Out of 580 patients, 161 patients had one or more comorbids. 39 out of 580 patients had history of previous abdominal surgery. 78 patients had tender right hypochonrium. 62 patients had palpable gall bladder. On ultrasound 73 patients had gall bladder wall thickness >4mm. In 39 patients pericholecystic fluid collection was found. In 33 patients, stone was impacted at the neck of gall bladder. 161 patients were preoperatively labeled as difficult. All the patients underwent laparoscopic cholecystectomy. Mean operative time was 42.56 minutes. 512 patients underwent uneventful laparoscopic cholecystectomy, in 68 patients difficulty was encountered 11 patients were converted to open procedure. Conclusion: We conclude that a careful insight in certain factors can predict the difficult laparoscopic cholecystectomy preoperatively. It acts as an important eye opener for surgeons to get an idea of the potential difficulty to be faced in that particular patient. Keywords: Laparoscopic cholecystectomy, Preoperative, Gall stones, Difficulty