Carbon Dioxide Insufflation Research Articles

Editorial to “Carbon dioxide insufflation to facilitate epicardial access in ECMO‐supported ventricular tachycardia ablation”

Editorial to “Carbon dioxide insufflation to facilitate epicardial access in <scp>ECMO</scp>‐supported ventricular tachycardia ablation”

Carbon dioxide insufflation to facilitate epicardial access in ECMO‐supported ventricular tachycardia ablation

Carbon dioxide insufflation to facilitate epicardial access in <scp>ECMO</scp>‐supported ventricular tachycardia ablation

Abstract 4124604: Finding the Right Course: Unknown Source of Hemorrhage Following Endocardial-Epicardial Ablation for Ventricular Tachycardia

Background: Epicardial radiofrequency ablation via percutaneous access is a common technique for ventricular tachycardia (VT) ablation. Rapid identification of and response to complications can reduce morbidity and mortality. Objective: We present a case of epicardial VT ablation complicated by a distal left internal mammary artery (LIMA) transection secondary to subxiphoid sheath insertion. Report: A 66-year-old man with hypertrophic cardiomyopathy was referred for endo-epicardial ablation of recurrent VT. Pericardial access was obtained using coronary vein exit and carbon dioxide insufflation technique. An 8.5F sheath was advanced over an indwelling pericardial wire, and ablation was performed. Following ablation, 400cc of blood was aspirated from the pericardial space after replacing the 8.5F sheath with a standard pericardial drain. Urgent angiography revealed intact coronary arteries, coronary sinus (CS) and LIMA. The 8.5F sheath was re-introduced and bleeding ceased. CT scan revealed no myocardial or great vessel damage. Mild pericardial drainage continued overnight. The next day, IR angiography demonstrated transection of the distal LIMA from the indwelling sheath. The patient underwent placement of a back-up pericardial drain, followed by coil embolization of the injured artery without complication (Fig). Conclusion: This case highlights the importance of maintaining a broad differential during apparent complications of epicardial access and the importance of staying close to midline for epicardial puncture given anatomic variability. The differential for acute blood loss and pericardial effusion following epicardial ablation includes 1) coronary artery damage, 2) CS damage, 3) extracardiac vascular injury, and 4) right ventricular injury. When extracardiac vascular injury is suspected, multidisciplinary collaboration is essential.

Gas embolism in double-balloon endoscopic retrograde cholangiography with carbon dioxide insufflation.

Gas embolism in double-balloon endoscopic retrograde cholangiography with carbon dioxide insufflation.

Progress in gasless endoscopic thyroidectomy.

Gasless endoscopic thyroidectomy obviates the necessity for carbon dioxide insufflation to establish a surgical workspace, thus mitigating the potential complications associated with this practice. This technique presents several benefits, such as the maintenance of neck functionality, minimal scarring, and enhanced visibility of the surgical field, which contribute to its extensive adoption in clinical settings. The objective of this study is to synthesize the current methodologies of gasless endoscopic thyroidectomy and to evaluate the advantages and disadvantages inherent to each technique. It aims to offer theoretical insights to assist surgeons in determining the most suitable approach for gasless endoscopic thyroidectomy in their clinical practice.

Intestinal ischemia: A rare and less common complication after laparoscopic cholecystectomy-A case report and literature review.

Patients with a history of persistent mesenteric ischemia should not undergo laparoscopy. Mesenteric ischemia must be kept in mind for patients who develop nonspecific abdominal symptoms following laparoscopic surgeries. During laparoscopic cholecystectomy (LC), the rise in Intra-Abdominal Pressure due to carbon dioxide insufflation can reduce blood flow through splanchnic vessels, potentially leading to intestinal ischemia. A 72-year-old woman with a history of diabetes, hypertension, ischemic heart disease, and hyperlipidemia underwent LC. She was discharged but readmitted 4 days later due to peritonitis. Ischemic jejunum loops were found during surgery.

Estimation of the difference between peritoneal microenvironment and core body temperature during laparoscopic surgery – a prospective observational study

Maintaining patients’ temperature during surgery is beneficial since hypothermia has been linked with perioperative complications. Laparoscopic surgery involves the insufflation of carbon dioxide (CO2) into the peritoneal cavity and has become the standard in many surgical indications since it is associated with better and faster recovery. However, the use of cold and dry CO2 insufflation can lead to perioperative hypothermia. We aimed to assess the difference between intraperitoneal and core temperatures during laparoscopic surgery and evaluate the influence of duration and CO2 insufflation volume by fitting a mixed generalized additive model. In this prospective observational single-center cohort trial, we included patients aged over 17 with American Society of Anesthesiology risk scores I to III undergoing laparoscopic surgery. Anesthesia, ventilation, and analgesia followed standard protocols, while patients received active warming using blankets and warmed fluids. Temperature data, CO2 ventilation parameters, and intraabdominal pressure were collected. We recruited 51 patients. The core temperature was maintained above 36 °C and progressively raised toward 37 °C as pneumoperitoneum time passed. In contrast, the intraperitoneal temperature decreased, thus creating a widening difference from 0.4 [25th–75th percentile: 0.2–0.8] °C at the beginning to 2.3 [2.1–2.3] °C after 240 min. Pneumoperitoneum duration and CO2 insufflation volume significantly increased this temperature difference (P < 0.001 for both parameters). Core vs. intraperitoneal temperature difference increased linearly by 0.01 T °C per minute of pneumoperitoneum time up to 120 min and then 0.05 T °C per minute. Each insufflated liter per unit of time, i.e. every 10 min, increased the temperature difference by approximately 0.009 T °C. Our findings highlight the impact of pneumoperitoneum duration and CO2 insufflation volume on the difference between core and intraperitoneal temperatures. Implementing adequate external warming during laparoscopic surgery effectively maintains core temperature despite the use of dry and unwarmed CO2 gases, but peritoneal hypothermia remains a concern, suggesting the importance of further research into regional effects.Trial registration: Clinicaltrials.gov: NCT04294758.

The Effect of Increased Intra-Abdominal Pressure on Hemodynamics in Laparoscopic Cholecystectomy-The Experience of a Single Centre.

Laparoscopic cholecystectomy is characterized by reduced postoperative pain, shorter hospital stays, rapid return to preoperative physical activity, and less psychological impact on the patient. During laparoscopic cholecystectomy, the intra-abdominal insufflation of carbon dioxide with secondary increase in intra-abdominal pressure can cause important hemodynamic consequences, like decreased cardiac output and blood pressure, as well as compensatory increase in heart rate. The purpose of this study is to evaluate changes in cardiovascular parameters during general anesthesia in patients undergoing laparoscopic cholecystectomy. Retrospective data from 342 patients with cholecystectomy for cholelithiasis performed at Railway Hospital Galati, Romania, were reviewed. All patients received the same intraoperative anesthetics. Female patients were 85.7% (n = 293). More than half of the patients, 53.51% (n = 183), were 40-59 years old, and only 16.37% (n = 56) were under 40 years old. Patients with a normal body mass index (BMI) represented 45.6% (n = 156), 33.3% (n = 114) were underweight, and 12% (n = 42) had grade 1 obesity (BMI 25-29.9 kg/m2). The minimum intraoperative blood pressure correlated with patient gender (p 0.015 < 0.005), with men having a higher blood pressure than women (p 0.006 < 0.05), and for BMI, a higher BMI was associated with elevated blood pressure (p 0.025 < 0.05). Older age correlated with an increased maximum intraoperative blood pressure (p < 0.001 < 0.05) and with maximum intraoperative heart rate (p 0.015 < 0.05). Patients undergoing laparoscopic cholecystectomy experienced significant hemodynamic changes with pneumoperitoneum, but this type of surgical intervention was safe for patients regardless of their age.

Fetal bradycardia in open versus fetoscopic prenatal repair of spina bifida.

To compare the occurrence of fetal bradycardia in open versus fetoscopic fetal spina bifida surgery. This is a single-institution retrospective cohort study of patients undergoing open (n=25) or fetoscopic (n=26) spina bifida repair between 2017 and 2022. From October 2017 to June 2020, spina bifida repairs were performed via an open classical hysterotomy, and from November 2020 to June 2022 fetoscopic repairs were performed following transition to this technique. Fetal heart rate (FHR) in beats per minute (bpm) was recorded via echocardiography every 15min during the procedure. Cohort characteristics, fetal bradycardia and maternal physiologic parameters were compared between the groups. Fetuses undergoing an open repair more frequently developed bradycardia defined as <110 bpm (32% vs. 3.8%, p=0.008), and a trend was observed for FHR decreases more than 25 bpm from baseline (20% vs. 3.8%, p=0.073). Profound bradycardia less than 80 bpm was rare, occurring in only three operations (two in open, one in fetoscopic repair) with two fetuses (one in each group) requiring emergency cesarean delivery. When compared to open fetal surgery, fetal bradycardia occurred less frequently in fetoscopic surgery despite a significantly greater anesthetic exposure and the use of the intraamniotic carbon dioxide insufflation.

Long-Term Outcomes of Carbon Dioxide Insufflation in Thoracoscopic Esophagectomy After Neoadjuvant Chemotherapy for Esophageal Squamous Cell Carcinoma: A Retrospective Cohort Study.

Thoracoscopic esophagectomy (TE) with carbon dioxide (CO2)insufflation is increasingly performed for esophageal cancer; however, there is limited evidence of the long-term outcomes of CO2 insufflation on postoperative survival. We investigated the long-term outcomes of TE with or without CO2 insufflation. We enrolled 182 patients who underwent TE for esophageal cancer between January 2003 and October 2013 and categorized them into two groups: with and without CO2 insufflation. The primary endpoint was five-year overall survival (5y-OS). Secondary endpoints included long-term outcomes, such as five-year relapse-free survival (5y-RFS) and five-year cancer-specific survival (5y-CSS), and short-term outcomes, such as surgical and non-surgical complications and reoperation within 30 days. Follow-up until death or the five-year postoperative period was 98.9% (median follow-up duration was six years in survivors). After adjusting for age, sex, and yield pathologic tumor, node, and metastasis (TNM) stage, we found no significant differences in 5y-OS (HR 1.12, 95% CI 0.66-1.91), 5y-RFS (HR 1.12, 95% CI 0.67-1.83), or 5y-CSS rates (HR 1.00, 95% CI 0.57-1.75). For short-term outcomes, significant intergroup differences in operation time (p=0.02), blood loss (p<0.001), postoperative length of stay (p<0.001), and incidence of atelectasis (p=0.004) were observed. The results of the sensitivity analysis were similar to the main results. In thoracoscopic procedures, CO2 insufflation significantly improved short-term outcomes, and it appears that the recurrence risk of esophageal cancer may not impact the long-term prognosis. While the influence of CO2 insufflation in thoracoscopic esophageal surgery remains unclear, our study suggests that the long-term prognosis is not compromised in other thoracic surgeries.

Combined use of dexmedetomidine and nalbuphine in laparoscopic radical gastrectomy for gastric cancer.

Radical laparoscopic gastrectomy is an important treatment modality for gastric cancer. Surgery requires general anesthesia, and patients are susceptible to the effects of anesthetic drugs and carbon dioxide insufflation during the procedure, leading to inflammation or severe pain, which can affect patient outcome. To explore the efficacy of combining dexmedetomidine (DEX) with nalbuphine in patients underwent laparoscopic radical gastrectomy for gastric cancer. Patients scheduled to undergo laparoscopic radical gastrectomy were selected and randomly assigned to A or B group. In A group, patients received an intravenous injection of nalbuphine 0.2 mg/kg + DEX 0.4 μg/kg 10 min before the end of surgery; in B group, patients received only an intravenous injection of nalbuphine. The trends in hemodynamic parameter fluctuations, awakening quality during the recovery period, serum inflammatory markers, agitation scores, cough severity, incidence, and duration of postoperative delirium (POD) were compared. The mean arterial pressure and heart rate in the A group were more stable (P < 0.05). The A group had a lower average awakening time, extubation time, and agitation scores during recovery than the B group. Agitation control in the A group was more effective at different time points (P < 0.05). Patients in the A group had lower serum interleukin (IL)-6, tumour necrosis factor alpha, and IL-10 levels at 1 h after surgery than the B group. The incidence of coughing and duration of POD were lower and shorter in the A group than in the B group. Adverse reactions caused by the two anesthesia methods were less frequent in the A group than in the B group (P < 0.05). The use of DEX and nalbuphine in patients undergoing laparoscopic radical gastrectomy for gastric cancer help reducing the inflammatory response, cough severity, and agitation and helps maintain hemodynamic stability.

MID–TERM OUTCOMES OF ENDOSCOPIC MITRAL VALVE REPAIR VIA RIGHT ANTERIOR MINI–THORACOTOMY

Abstract The adoption of less–invasive mitral repair (MVr) surgery is increasing, backed by evidence of satisfactory short–term results and lower major morbidity. We assessed mid–term follow–up results of our experience, and compared two techniques: isolated leaflet resection and neochord implantation for posterior leaflet (PML) prolapse. Between 2012–2021, 700+ operations were performed with a video–assisted right mini–thoracotomy (RMT) approach. We report 309 consecutive patients who had endoscopic MVr, including those receiving concomitant tricuspid repair, ablation for atrial fibrillation, closure of patent foramen ovale and/or left atrial appendage. The early and mid–term follow–up results were ascertained. Primary outcome was the incidence of mortality and significant mitral regurgitation (MR) during follow–up which were summarized by Kaplan–Meier estimator and compared between treatment arms via log–rank test. Secondary outcomes were the early–postoperative results including 30–days mortality and major complications. All patients had endoscopic MVr via RMT at the 3rd/4th intercostal space (IS). A soft–tissue retractor is used, accompanied or not by a rib spreader, and two ports in the fourth and sixth IS are used for 3D thoracoscopy and carbon dioxide insufflation. Femoral vessels exposure through a right groin incision and echo–guided cannulation sec. Seldinger is achieved post–heparinization. Thoracic fascia bisection is performed during single–lung ventilation using a double–lumen endotracheal tube, integral to our anesthetic management, including percutaneous right internal jugular vein cannulation. The pericardium is opened and an aortic root cannula for cardioplegia delivery and venting is placed via working incision. After establishing cardiopulmonary bypass, a Chitwood clamp is passed through the second IS and cardioplegia is delivered. Endoaortic balloon clamping is primarily used in redo cases. With ring annuloplasty, 136 (44%) patients received PML resection (122 isolated) and 97 (31%) PML chords implantation (88 isolated). Forty–nine patients had annuloplasty alone. In–hospital mortality was 1.0%. Mean follow–up was 29±22 months (max 8.3 years). Kaplan–Meier 5–year survival was 97.3±1.0%. MR (3/4+) free–survival at 5 years was 94.5±2.3%. Subgroup time–to–event analysis for the indexed outcomes showed no statistical significance between techniques. In conclusion, endoscopic MVr is safe with excellent mid–term outcomes.

The Safety and Efficacy of Epicardial Carbon Dioxide Insufflation Compared With Conventional Epicardial Access

BackgroundEpicardial (Epi) access is commonly required during ventricular tachycardia ablation. Conventional Epi (ConvEpi) access targets a “dry” pericardial space presenting technical challenges and risk of complications. Recently, intentional puncture of coronary venous branches with Epi carbon dioxide insufflation (EpiCO2) has been described as a technique to improve Epi access. The safety of this technique relative to conventional methods remains unproven. ObjectivesThe authors sought to compare the feasibility and safety of EpiCO2 to ConvEpi access. MethodsAll patients at a high-volume center undergoing Epi access between January 2021 and December 2023 were included and grouped according to ConvEpi or EpiCO2 approach. Access technique was according to the discretion of the operator. ResultsEpi access was attempted in 153 cases by 17 different operators (80 ConvEpi vs 73 EpiCO2). There was no difference in success rate whether the ConvEpi or EpiCO2 approach was used (76 [95%] cases vs 67 [91.8%] cases; P = 0.4). Total Epi access time was shorter in the ConvEpi group compared with the EpiCO2 group (16.3 ± 11.6 minutes vs 26.9 ± 12.7 minutes; P < 0.001), though the total procedure duration was similar. Major Epi access–related complications occurred in only the ConvEpi group (6 [7.5%] ConvEpi vs 0 [0%] EpiCo2; P = 0.02). Bleeding ≥80 mL was more frequently observed following ConvEpi access (14 [17.5%] cases vs 4 [5.5%] cases; P = 0.02). After adjusting for age, repeat Epi access, and antithrombotic therapy, EpiCO2 was associated with a reduction in bleeding ≥80 mL (OR: 0.27; 95% CI: 0.08-0.89; P = 0.03). ConclusionsEpiCO2 access is associated with lower rates of major complication and bleeding when compared with ConvEpi access.

Retained intracardiac air in cardiovascular surgery: a re-visited problem.

Intracardiac air remains an unsolved problem in the realm of cardiac surgery, leading to embolic events encompassing conduction disturbance, heart failure, and stroke. Transesophageal echocardiography allows the visualization of three distinct types of retained intracardiac air: pooled air, coarse bubbles, and microbubbles. The former two predominantly manifest in the right upper pulmonary vein, left atrium, and left ventricle, exhibiting passive movement along the vessel walls by buoyancy. De-airing, involving "eradication" of air from circulation and "expulsion" of air from the heart into the systemic circulation assumes paramount importance in averting embolic events. Optimal de-airing strategies necessitate the thorough elimination of air during the static phase before the resumption of cardiac activity, achieved through aspiration or guided exit leveraging buoyancy. While the dynamic phase, characterized by active cardiac beating, presents challenges for air eradication, the majority of air expulsion occurs towards the aorta during this period. In this latter phase, collaborative efforts among the surgeon, anesthesiologist, and clinical engineer are pivotal to mitigate the risk of bolus air embolism. The efficacy of carbon dioxide insufflation is limited, as it is rapidly aspirated by wall suction or absorbed into the bloodstream. Consequently, the "air" identified by TEE is acknowledged as conventional air. Understanding the distinctive properties of air as well as timely and judicious collaboration for detection and removal, with the ultimate goal of eradication, emerges as an essential prerequisite for successful de-airing in the evolving era of cardiac surgery.

Assessment of pericardial adhesions by means of the EpiCO2 technique: Brighton Adhesion Classification

BackgroundEpicardial ablation complications are more frequent in patients with preexisting pericardial adhesions. As opposed to the dry puncture technique, the coronary vein exit and carbon dioxide (CO2) insufflation (EpiCO2) technique allows diagnosing pericardial adhesions before subxiphoid puncture. ObjectiveThis study aimed to evaluate the efficacy of the EpiCO2 technique in diagnosing pericardial adhesions prior to subxiphoid puncture. MethodsFollowing coronary vein exit, contrast was injected in the pericardial space, and adhesions classified using our novel Brighton Adhesion Classification (BAC) into BAC-0 (no adhesions), BAC-1 (dispersed adhesions), and BAC-2 (dense adhesions extending to the entire assessed area). CO2 insufflation allowed subclassification of BAC-1 adhesions into BAC-1a (not preventing epicardial access or restricting catheter movement) and BAC-1b (either preventing epicardial access or significantly limiting catheter movement). ResultsIntentional coronary vein exit (right atrial appendage exit in 1 case) was achieved in all 235 consecutive epicardial ablation procedures undertaken at our center. A diagnosis of BAC-0 was made in 219 cases (93.2%), BAC-1a in 9 cases (3.8%), BAC-1b in 2 cases (0.9%), and BAC-2 in 5 cases (2.1%). This led to not attempting subxiphoid puncture in 6 cases (2.6%) and abandoning epicardial mapping because of limited catheter movement in 1 case (0.4%). Access-related complications occurred in 7 cases (3%) only in the BAC-0 group. ConclusionThe EpiCO2 technique allows assessment of the presence of pericardial adhesions prior to attempting subxiphoid puncture for epicardial access, which may lead to a reduction in the procedural complications within this subset of patients.

Restoration of Pulmonary Compliance after Laparoscopic Gynecologic Surgery Using a Recruitment Maneuver.

This study aimed to investigate the hypothesis that an alveolar recruitment maneuver can restore lung compliance to initial values after laparoscopic gynecological surgery. A total of 31 patients who underwent laparoscopic gynecological surgery were enrolled. Protective mechanical ventilation was applied, and the radial artery was catheterized in all patients. An alveolar recruitment maneuver (incremental and decremental positive end-expiratory pressure) was applied ten minutes after the release of pneumoperitoneum. The respiratory mechanics and blood gas results were recorded at eight different time points: after induction of anesthesia (T1), in the lithotomy position (T2), in the Trendelenburg position (T3), 10 and 90 min after insufflation of carbon dioxide (T4 and T5), in the supine position (T6), after desufflation (T7), and 10 min after an alveolar recruitment maneuver at the end of surgery (T8). Pneumoperitoneum and the Trendelenburg position caused a decline of 15 units in compliance (T7 vs. T1; p < 0.05) compared to baseline. After the alveolar recruitment maneuver, compliance increased by 17.5% compared with the mean value of compliance at time T1 (T8 vs. T1; p < 0.05). The recruitment maneuver had favorable results in patients with low initial compliance (41.5 mL/cmH2O, IQR: 9.75 mL/cmH2O), high Body Mass Index 30.32 kg/m2 (IQR: 1.05 kg/m2), and high initial plateau airway pressure (16.5 cmH2O, IQR: 0.75 cmH2O). Lung compliance does not return to initial values after performing laparoscopic gynecological procedures. However, after the release of pneumoperitoneum, an alveolar recruitment maneuver is beneficial as it improves compliance and gas exchange.

Intraoperative Patient Warming Instead of Gas on the Management of Postoperative Pain in Laparoscopic Colectomy and Cholecystectomy: A Randomized Controlled Trial.

Blurred lines remain in details of the association between patient warming with postoperative pain and a proper analgesic requirement. Therefore, the present study proposes to observe the effects of intraoperative patient warming and carbon dioxide insufflation duration in laparoscopic colectomy (LCol) andlaparoscopic cholecystectomy (LChol) procedures on postoperative pain, analgesic requirements, and hemodynamics. The present study involved 80 cases aged 18-80 years with the American Society of Anesthesiologists I-III classification, possessing two initial groups primarily, one for LCol and one for LChol. Subsequently, each was divided into two through randomization for intraoperative warming. Postoperatively, pain perception, per se, was evaluated using the visual analog scale (VAS) score at the 30 minutes, 1st, 6th, 12th, and 24th hours, along with the impact of pain on hemodynamic parameters and side effects such as nausea/vomiting and the dosage of analgesics used. Groups actively heated with warm air-blowing devices detected significantly higher intraoperative core and skin temperature measurements, and postoperative early pain perception was significantly lower in the warmed ones. Furthermore, a significant decrease in the VAS scores and the analgesic at the 12th and 24th hours compared to the first six hours was recognized between them. Consequently, herewith, we postulate that so-called patient warming positively affects the VAS scores.

Evaluation of hepatic and renal functional changes in patients undergoing laparoscopic cholecystectomy

Background: In this era of laparoscopic surgery, with the use of carbon dioxide insufflation in creating pneumoperitoneum for ease of trocar insertion and visualization of anatomy, it comes certain systemic changes in the patient due to the compression effect of the gas as well as resorption of it through peritoneum. Aims and Objectives: The aim of the study was to assess baseline standards of hepatic and renal functional status in pre-operative patients in comparison with post-operative patients undergoing laparoscopic cholecystectomy (LC). Materials and Methods: Cases were chosen among the persons who presented with chronic calculus cholecystitis to the surgical out-patient department of Ramakrishna Mission Seva Pratishthan, Vivekananda Institute of Medical Sciences, Kolkata. Pre-operative liver function tests (LFT) and renal function tests (RFT) values were recorded. Again, LFT and RFT values were evaluated on post-operative day 1 (POD1) and POD12. Results: Serum conjugated and unconjugated bilirubin, aspartate amino transaminase, alanine amino transaminase, urea, estimated glomerular filtration rate values increases immediate postoperatively on POD1 but returns to normal pre-operative levels on POD 12. Serum alkaline phosphatase, albumin, and creatinine values decrease on POD1 and return to normal pre-operative values in POD 12. Conclusion: Hepatic and renal function changes in the immediate post-operative period of 24 h following LC. This change is transient and returns to normal levels within POD 12.

Dry Knee Arthroscopy With Carbon Dioxide Insufflation for Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) injuries are commonly treated through orthopaedic surgery, with traditional procedures relying on arthroscopy using fluid as the medium. However, dry arthroscopy has emerged as a potentially advantageous alternative technique. This method allows the knee joint to remain dry, reducing the risk of fluid leakage and enabling a more precise surgical visualization, resulting in shorter operation times and fewer complications. Recent research has highlighted the benefits of carbon dioxide (CO2) insufflation during ACL reconstruction, which can decrease pain and discomfort during early recovery. This article introduces a technique for performing ACL reconstruction that eliminates the need for arthroscopic fluid for visualization or instrumentation. Based on CO2 insufflation, this technique shows promise as a viable alternative to traditional fluid distention methods.

Cardiac Tamponade Caused By Carbon Dioxide Insufflation During Robot-Assisted Thoracic Surgery: A Case Report.

Various complications can occur during robot-assisted thoracic surgery for mediastinal tumors owing to carbon dioxide (CO2) insufflation. This study reports the case of a 43-year-old woman who underwent robot-assisted surgery for an anterior mediastinal tumor with the subxiphoid approach. Shortly after starting CO2 insufflation, the blood pressure decreased significantly. Subsequent examination of the mediastinum revealed a left-sided pericardial injury. Cardiac tamponade due to entry of CO2 gas into the pericardial cavity was suspected. A deliberate incision was made in the right pericardium, ultimately resolving the cardiac tamponade and substantially improving the patient's blood pressure.