Transesophageal echocardiographic detection of gas embolism and cardiac valvular dysfunction during laparoscopic nephrectomy

We used transesophageal echocardiography (TEE) to monitor venous gas emboli sm, cardiac performance, and the hemodynamic effects of positioning and pne umoperitoneum in 16 healthy kidney donors undergoing laparoscopic nephrecto my. A four-chamber view was used continuously, except at predetermined inte rvals, when a complete TEE, examination for cardiac function was performed. Other clinical variables recorded include systolic, diastolic, and mean ar terial blood pressure; heart rate (HR), pulse oximetric saturations; and en d-tidal CO2. Baseline valvular incompetence was seen in 13 of the 16 patien ts when supine and asleep, After positioning for surgery and induction of p neumoperitoneum, TEE revealed valvular incompetence with regurgitation more pronounced from baseline in 15 of the 16 patients, In one patient, during renal vein dissection, gas entered the right atrium from the inferior vena cava, worsening tricuspid regurgitation. Hemodynamic variables and ejection fraction were tested by using repeated measures analysis of variance for s ignificance (P < 0.05). Pneumoperitoneum increased (P < 0.05) systolic bloo d pressure (from 102.8 +/- 3.89 to 120.8 +/- 3.88 mm Hg) and HR (from 68.9 +/- 3.19 to 75.6 +/- 2.62). Ejection fraction was unchanged. The high incid ence of valvular incompetence indicates that further studies are needed to assess these effects during laparoscopic nephrectomy with cardiac disease. Implications: Laparoscopic surgery has gained popularity as a procedure for the removal of donated kidneys. Although the insufflation of gas necessary for this relatively simple approach poses a low risk of venous air embolis m, it may increase the risk of changes in valvular competency.