What is the next step when poor tidal volumes are noted during a laparoscopic partial nephrectomy while using the Argon Beam Coagulator (ABC)?

From the Guidelines

The next step during a laparoscopic partial nephrectomy when poor tidal volumes are noted while using the argon beam coagulator is to immediately stop using the argon beam coagulator and check for a gas embolism, as this situation can lead to a potentially life-threatening complication. The anesthesia team should be notified right away, and the patient should be placed in the left lateral decubitus position with the head down (Durant position) to prevent gas from entering the cerebral circulation, as recommended by general surgical principles. The surgical field should be flooded with saline to prevent further gas entry, and the pneumoperitoneum pressure should be reduced or temporarily released. This situation represents a potentially life-threatening complication where argon gas is entering the venous circulation through open vessels at the surgical site. The poor tidal volumes occur because the gas embolism impedes pulmonary blood flow, creating ventilation-perfusion mismatch. Hemodynamic monitoring should be intensified, and supportive measures including supplemental oxygen and vasopressors may be needed if hypotension develops, following the principles outlined in the study by 1. Once the patient is stabilized, the surgery can cautiously resume with alternative hemostatic methods, considering the use of low tidal volume (6–8 ml/kg predicted body weight) and positive end-expiratory pressure, as recommended by the study 1. Key considerations include:

• Stopping the use of the argon beam coagulator
• Notifying the anesthesia team
• Placing the patient in the Durant position
• Flooding the surgical field with saline
• Reducing or releasing pneumoperitoneum pressure
• Intensifying hemodynamic monitoring
• Providing supportive measures as needed
• Resuming surgery with alternative hemostatic methods and considering low tidal volume and positive end-expiratory pressure.

From the Research

Next Steps for Poor Tidal Volumes during Laparoscopic Partial Nephrectomy

• The use of the argon beam coagulator during laparoscopic partial nephrectomy can lead to poor tidal volumes, which may be mitigated by adjusting the ventilation strategy 2.
• Low tidal volume ventilation (LTVV) has been shown to reduce postoperative pulmonary complications (PPCs) in patients undergoing laparoscopic surgery, and may be a suitable approach in this scenario 2.
• The argon beam coagulator has been found to be a safe and effective method for achieving hemostasis during laparoscopic partial nephrectomy, with benefits including reduced warm ischemia time and estimated blood loss 3, 4.
• Close monitoring of intra-abdominal pressure and frequent venting can help avoid complications associated with the use of the argon beam coagulator 3.
• The choice of ventilation strategy and hemostatic method should be tailored to the individual patient's needs and the specific requirements of the procedure.

Considerations for Ventilation Strategy

• The use of LTVV with a tidal volume of 6 mL/kg predicted body weight and a positive end-expiratory pressure (PEEP) of 5 cmH2O may be a suitable approach for patients undergoing laparoscopic partial nephrectomy 2.
• The benefits of LTVV in reducing PPCs should be weighed against the potential risks and challenges of implementing this ventilation strategy in the context of laparoscopic surgery 2.

Hemostatic Methods

• The argon beam coagulator is a well-established method for achieving hemostasis during laparoscopic partial nephrectomy, with a proven track record of safety and efficacy 3, 4.
• Alternative hemostatic methods, such as internal renorrhaphy, may also be effective in achieving hemostasis during laparoscopic partial nephrectomy, but may have different benefits and drawbacks compared to the argon beam coagulator 3.