laparoscopic surgery has established itself as a durable alternative for both gynecologic and general surgical procedures . with increasing popularity and greater utility , the types and number of reported complications are increasing .
we describe the case of a 70-year - old male undergoing routine laparoscopic cholecystectomy for gallstone pancreatitis who developed asystolic cardiac arrest intraoperatively .
a review of the literature revealed 2 cases of asystolic cardiac arrest during laparoscopy : one was during laparoscopic cholecystectomy and one was during diagnostic laparoscopy for gynecologic evaluation .
a 70-year - old male with a past medical history negative for ischemic heart disease with asymptomatic myocardial infarction was admitted to the hospital with a 24-hour history of severe , acute epigastric abdominal pain .
his point of maximal impulse was nondisplaced , and he had no evidence of jugular venous distension .
his abdomen was soft with no masses , hernias , or palpable evidence of organomegaly .
he demonstrated mild to moderate tenderness to palpation of his epigastrium and right upper abdominal quadrant .
initial investigations included the following tests : complete blood count : white blood cell count 14.6 ; hemoglobin / hematocrit 15.1/44.5 , platelets 399 000 ; basic metabolic profile : na 138 , k 4.1 , cl 103 , co2 26 , urea 14 , creatinine 0.9 , glucose 138 ; liver function tests : total bilirubin 0.8 , albumin 3.1 , aspartate aminotransferase ( ast ) 576 , alanine aminotransferase ( alt ) 417 , alkaline phosphatase 352 , ldh 1639 ; amylase 1173 ; lipase 5339 .
initial electrocardiography revealed regular rhythm with first - degree av block and no evidence of acute coronary ischemia .
a chest xray showed mild cardiomegaly , hyperinflated lungs , and no evidence of infiltrate or congestion .
ultrasonography of the gallbladder showed several gallstones with a common bile duct measurement to 8 mm , no wall thickness , and no evidence of pericholecystic fluid .
he was not allowed to take anything by mouth and was started on empiric intravenous antibiotics for presumed persistent common bile duct obstruction . over ensuing days ,
the patient 's laboratory evaluations showed a continuously decreasing amylase and lipase until normality was achieved on hospital day number 4 .
it was deemed that the patient would require endoscopic retrograde cholangiopancreatography ( ercp ) and cardiology clearance prior to undergoing laparoscopic cholecystectomy .
because the patient 's acute symptomology had entirely resolved and he was tolerating a regular diet without recurrence of pain , he was discharged home with plans to undergo ercp and cardiac evaluation as an outpatient .
ercp was attempted by a well - experienced gastroenterologist ; cannulation of the sphincter of oddi was unsuccessful secondary to a duodenal diverticulum , and the procedure was aborted .
cardiac assessment consisting of a stress test was performed , which was negative for unstable coronary circulation .
the patient returned to the hospital 6 weeks after the initial evaluation for laparoscopic cholecystectomy . in the interim
, he had been doing well , tolerating a low - fat diet , and had stopped smoking 2 weeks prior to the scheduled surgery .
preoperative medication comprised mefoxin and was discontinued approximately 30 minutes prior to the scheduled surgery . in the operating room ,
the patient was preoxygenated with 80% oxygen to achieve a peripheral pulse oxygen saturation of 100% .
appropriate intubation was confirmed by positive end - tidal co2 and auscultation of administered breaths in bilateral lung fields .
anesthesia was maintained with nitrous oxide and fentanyl . in the supine position , access into the peritoneal cavity was attained using the open hassan technique via an intraumbilical incision .
pneumoperitoneum was initially achieved to an intraperitoneal pressure of 15 mm hg by first administering low - flow co2 followed by high - flow co2 .
the gallbladder was then grasped with a gallbladder grasper and retracted in the lateral / cephalad direction for approximately 15 seconds resulting in an asystolic episode for 30 seconds .
the patient was administered atropine , with subsequent resumption of sinus cardiac rhythm . with resumption of stable vital signs , reinsufflation of the peritoneal cavity to 15 mm hg
sinus rhythm was achieved within 5 seconds of releasing the gallbladder and relieving the pneumoperitoneum .
a third attempt at gallbladder manipulation was made without insufflation but with direct visualization of the gallbladder .
cardiac rhythm resumed approximately 5 seconds after the gallbladder was released . throughout all 3 episodes , adequacy of ventilation
was confirmed bilaterally , oxygen saturation remained at 100% , capnometry readings of 35 to 40 mm hg were obtained , and the patient remained normothermic .
no acute electrocardiographic changes were appreciated with resumption of cardiac rhythm in the operating room .
the patient was extubated in the operating room , transferred to the postanesthesia recovery room , and maintained on telemetry .
postoperative cardiology and electrophysiology evaluation did not reveal a primary cardiac event as the cause of the patient 's asystolic episodes .
additionally , the patient 's cardiac isoenzyme profile over the 24-hour period was negative for acute myocardial injury . given these findings coupled with the patient 's respiratory stability intraoperatively , it was deemed that a severe vagal reaction in response to gallbladder retraction was the source of the patient 's asystolic episodes . therefore , the patient underwent insertion of a temporary pacemaker prior to a reattempt at a laparoscopic cholecystectomy .
the pacer was set to a rate greater than the patient 's resting heart rate .
the second procedure was performed using a pneumoperitoneum of 15 mm hg and was accomplished without incident .
the pacemaker was removed in the early postoperative period , and the patient was discharged home without further incident .
the causes of cardiovascular collapse during laparoscopy include co2 pulmonary embolization , cardiac arrhythmias , vagal reactions secondary to peritoneal distention during insufflation or viscus manipulation , and diminished cardiac preload secondary to caval compression .
asystolic cardiac arrest is a potential manifestation of these hemodynamically significant events . in a review of the literature ,
the american association of gynecology reports an incidence of one in 2500 cases of asystolic arrest during laparoscopy .
we were able to identify only one previously described case of asystole during laparoscopic cholecystectomy .
the clinical manifestation generally includes a diminished end - tidal co2 , tachycardia , diminished breath sounds in a specific lung field on auscultation , and a classic cardiac murmur associated with gas embolization .
the general mechanism is perceived to be infiltration of insufflated co2 into venous / lymphatic channels with subsequent pulmonary migration .
it is unlikely that the asystolic arrest in our case is secondary to gas embolization because our patient failed to exhibit any of the above signs .
an alternative cause of hemodynamically significant cardiovascular changes during laparoscopy is hypoxia or hypercapnia resulting in cardiac arrhythmias .
it is believed that the combination of the trendelenburg positioning and elevated intraabdominal compartment pressures predispose a patient to aspiration , resulting in hypoxia and possibly hypercapnia .
however , it is unlikely that clinically significant elevations in co2 levels on blood - gas measurements can be detected
. elevated intraabdominal pressures can diminish venous return to the heart , preload , resulting in diminished cardiac output . with intraabdominal pressures ranging from 12 to 15 mm hg ,
however , with intraabdominal pressures in excess of 40 mm hg , a significant caval compression leads to a decreased preload and cardiac output .
the first is an increase in central blood volume due to the forcing of blood out of the splanchnic circulation .
the second is a diminished preload secondary to peripheral pooling of blood in the lower extremities in combination with the reversed trendelenburg position .
the result is a temporary increase in circulating blood volume followed by a sustained decrease in central pressures .
these typically occur in patients with primary pulmonary pathology , such as pulmonary / mediastinal blebs , which rupture under positive pressure .
lehman et al delineate the possibility of tension pneumothorax during insufflation secondary to a congenital diaphragmatic defect .
cases of pneumothorax / pneumomediastinum generally present with hypotension , tachycardia , diminished breath sounds in a lung field , and possibly subcutaneous emphysema .
shifren et al1 describe a case of asystolic cardiac arrest during gynecologic laparoscopy that is attributed to rapid peritoneal distension during insufflation . under circumstances of elevated intraabdominal pressures
, it is postulated that manipulation of certain pelvic structures/ organs may further elevate intraabdominal pressures .
we do not believe this to be the cause in our case . even during gallbladder handling without pneumoperitoneum , asystole occurred.1 it is our opinion that the asystolic cardiac arrest in our case was secondary to a severe vagal reaction that was triggered by manipulation of the gallbladder .
this was validated by the fact that recurrent asystole was documented for approximately 5 seconds upon grasping the gallbladder without elevated intraabdominal pressures .
additionally , no reproducible hemodynamic sequelae occurred during the successful attempt at laparoscopic cholecystectomy , once the temporary pacemaker was in place
. we could not identify any clinical criteria , including altered co2 levels , hypoxia , diminished breath sounds , or tachycardia to suggest any of the other proposed mechanisms of cardiovascular collapse during laparoscopy that are described above .
 laparoscopic surgery has become a durable alternative for both gynecologic and general surgical procedures , but reported complications are increasing . 
 we describe the case of a 70-year - old male undergoing routine laparoscopic cholecystectomy for gallstone pancreatitis who developed asystolic cardiac arrest intraoperatively . 
 a review of the literature revealed 2 cases of asystolic cardiac arrest during laparoscopy : one was during laparoscopic cholecystectomy and one was during diagnostic laparoscopy for gynecologic evaluation . 