Cerebral Embolism Following Laparoscopic Surgery

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I read with special interest the case report of a laparoscopic nephrectomy donor death due to cerebral gas embolism published in your January 27, 2005 issue (1). Donor death in a living donation transplant program is a very serious issue and as rightly pointed out by authors, there are valuable lessons to be learnt from each such death to prevent any future recurrence of such unfortunate events. One appreciates that authors have not only reported this death but also attempted to dissect the circumstances to identify a possible cause of this death.
On closer examination of this case report, several issues come up which would need to be clarified before we attribute this death to cerebral gas embolism. First of all, it is not clear how the gas entered from venous system into the arterial system especially because the cardiac ultrasound was completely normal in this patient. In another similar case report of gas embolism following laparoscopic cholecystectomy, patient was found to have atrial septal defect (2). One also wonders if the neurological features could be attributed to cerebral anoxia resulting from intraoperative hypotension following blood loss especially because the postoperative EEG findings of diffuse epileptic activity and CT scan findings of diffuse brain edema are very nonspecific in nature and can be seen with a variety of clinical conditions.
It is also regretted that an autopsy could not be performed as it could possibly have provided some useful clues. One understands the difficulties in diagnosing cerebral gas embolism in laparoscopic surgery because of rapid absorption of carbon dioxide. But that is probably why it is so important to exercise caution before attributing a death to it.

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