Ann Thorac Surg 2000;69:1937-1938
© 2000 The Society of Thoracic Surgeons
Case reports
Pneumoperitoneum secondary to endoscopic harvest of saphenous vein graft
Andreas Lehmann, MDa,
Johannes Langa,
Udo Weisseb,
Joachim Boldt, MDa
a Departments of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany
b Department of Cardiac Surgery, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany
Address reprint requests to Dr Boldt, Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Bremserstr 79, D-67063 Ludwigshafen, Germany
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Abstract
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Endoscopic harvest of saphenous vein graft for coronary artery bypass grafting decreases leg wound complications compared with traditional longitudinal incision. A case of pneumoperitoneum secondary to endoscopic harvest of saphenous vein using insufflation of carbon dioxide is reported. Hypercarbia, increased peak airway pressure, but no significant changes of hemodynamics, or myocardial ischemia were noted. The management of this rare complication is described.
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Introduction
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Endoscopic harvest of saphenous vein graft is a clinically feasible surgical technique with a significant reduction in morbidity and a perfect cosmetic result in coronary artery bypass grafting (CABG) patients [1–3]. To the authors knowledge no severe complications have been reported for endoscopic saphenous vein harvesting. This is a report of a pneumoperitoneum caused by the insufflation of carbon dioxide (CO2) during the endoscopic procedure.
A 62-year-old, 73-kg, 172-cm woman was scheduled for coronary artery revascularization. The patient complained for angina pectoris at rest (C.C.S II) during the previous four months. Coronary angiography showed three vessel coronary artery disease (CAD) with well preserved left ventricular function. Risk factors for CAD were arterial hypertension and hyperlipidemia.
Endoscopic harvest of saphenous vein graft started at the right upper leg. The endoscopic system was Vasoview (Origin, Menlo Park, CA) using an insufflation of CO2 (Electronic Endoflator 264305 20, Karl Storz, Tuttlingen, Germany). The flow of CO2 can be adjusted to a maximum of 12 L/min and a peak pressure ranging from 15 to 30 mm Hg. Peak pressure at our institution is adjusted to 18 mm Hg, requiring a flow of CO2 from 0 to about 2 L/min. After 60 minutes 30 cm of vena saphena magna were harvested and to get more vein grafts endoscopic procedure was started at the left upper leg. Thirty minutes later the abdomen enlarged significantly and endexspiratory pCO2 increased from 30 to 37 mm Hg, peak airway pressure increased from 17 mm Hg to 23 mm Hg. Arterial pCO2 increased to a maximum of 52.3 mm Hg but could be quickly normalized by increasing tidal volume. Only mild respiratory acidosis (pH: 7.31) occurred. There were no significant changes of hemodynamics except moderate increases in pulmonary vascular resistance from 99 to 159 dyn sec cm-5. Mean pulmonary arterial pressure and pulmonary capillary wedge pressure remained unchanged. No signs of myocardial ischemia were noted. In close cooperation with the surgeon we decided to continue endoscopic harvesting of saphenous vein. The therapy of this complication was a close monitoring of pulse oxymetry, capnometry, blood gas analyses, and hemodynamics. Except increasing tidal volume for an increased ventilation no specific therapy was necessary.
After complete revascularization the patient was weaned uneventfully from cardiopulmonary bypass. The patient was transferred to the intensive care unit with stable hemodynamics. The abdomen was normal and no subcutaneous emphysema was noted. Postoperative chest roentgenogram showed a complete resorption of CO2, no subcutaneous emphysema or gas below the diaphragm was seen. A resternotomy was necessary during the first postoperative night due to excessive bleeding. The patient was extubated within 8 hours after resternotomy and no further complication was noted.
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Comment
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Endoscopic harvest of saphenous vein is advantageous to conventional open harvest in CABG patients because of excellent cosmetic results, less wound pain and lower rate of complications [1– 3]. Minor complications for open saphenectomy-like hematoma, wound dehiscence, infection, and pain are reported in up to 24% [3]. Major complications requiring surgical intervention-like bleeding and abscess are less than 1% [3]. Harvest rate for endoscopic technique is slower than for conventional saphenectomy [1, 2].
In all endoscopic techniques a subcutaneous dissection tunnel around saphenous veins is created. The insufflation of CO2 into this tunnel facilitates the preparation of the vein and stops small bleedings. Other authors [1, 3] visualize and dissect the vein directly, without using an insufflation of CO2. Whether our technique using the insufflation of CO2 is superior to endoscopic procedures direct dissecting the vein, must be evaluated in further studies.
No major intraoperative complications during endoscopic harvesting of saphenous vein have been reported [1–3]. In 5.6% a conversion from endoscopic to conventional harvest was necessary [1]. In a series of more than 100 patients at our institution, using insufflation of CO2, only one patient developed a pneumoperitoneum secondary to endoscopic harvest of saphenous vein. CO2 expanded in the subcutaneous tissue of the leg, passed along the groin vessels into the retroperitoneum and diffused into the abdominal cavity. In abdominal and thoracic endoscopic procedures the insufflation of CO2 is a common technique and its side effects are well known [4, 5]. The increased intraabdominal pressure can disturb alveolar ventilation by alveolar collapse leading to compromised oxygenation [4]. The insufflated CO2 is absorbed by the blood to an unpredictable extent and must be eliminated by the lungs by an increased ventilation [4]. The increased intraabdominal pressure reduces venous return and can compromise circulation, adequate volume substitution is essential [5]. These effects are more pronounced in infants [5].
The effects of increased intraabdominal pressure are correlated with its height. For patients with a decreased cardiopulmonary reserve an intraabdominal pressure of less than 10 to 12 mm Hg is recommended to minimize the side effects of CO2 insufflation [6–8].
Surgeons must be aware of the problems caused by the insufflation of CO2 for the endoscopic harvest of saphenous veins in CABG patients. The limited experience with endoscopic harvesting of saphenous veins does not allow to state generally accepted rules to flow and peak pressure of the insufflation of CO2. The risk of complications seems to rise the longer the procedure lasts, the more CO2 is insufflated, and the higher the peak pressure of insufflation of CO2 is adjusted. If any severe complications are noted the endoscopic procedure should be immediately converted into an open saphenectomy.
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References
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Allen K.B., Griffith G.L., Heimansohn D.A., et al. Endoscopic versus traditional saphenous vein harvesting. Ann Thorac Surg 1998;66:26-32.[Abstract/Free Full Text]
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Taura P., Lopez A., Lacy A.M., et al. Prolonged pneumoperitoneum at 15 mmHg causes lactic acidosis. Surg Endosc 1998;12:198-201.[Medline]
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Accepted for publication November 1, 1999.
Related Article
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Invited commentary
- Friedhelm Beyersdorf
Ann. Thorac. Surg. 2000 69: 1938.
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