Fatal carbon dioxide embolism as an unreported complication of retroperitoneoscopy

Retroperitoneoscopy has gained popularity because it offers a safe alternat ive to the more debilitating open approach and avoids postoperative ileus. However, this type of procedure carries certain disadvantages in terms of i ntraperitoneal effusions and hemodynamic changes. Major complications are e xceptional. We describe the case of a 52-year-old man who died of carbon di oxide embolism during elective totally extraperitoneal (TEP) inguinal herni oplasty for symptomatic left indirect inguinal hernia. With the patient und er general anesthesia, the retroperitoneal space was gained through a 1.5-c m incision made below the umbilicus. During the dissection, the patient col lapsed and could not be resuscitated, At autopsy, air bubbles were admixed with blood in the epicardial veins, but no injury to vessels was demonstrat ed. We conclude that carbon dioxide embolism usually is caused by direct pu ncture of major vessels during intra-abdominal procedures. However, when th is complication occurs during retroperitoneoscopy, it seems related to pres sure-forced entry of carbon dioxide into the venous plexus.