Complications of Laparoscopic Surgery

Case Synopsis

A 75-year-old man with dyslipidemia and hypertension is scheduled for elective laparoscopic repair of hiatal hernia. He has been on nothing-by-mouth (NPO; from the Latin, nil per os ) status for 12 hours except for his antihypertensive medications (losartan and hydrochlorothiazide). During induction of general anesthesia, his systolic blood pressure drops to 85 mm Hg. The patient receives a 500-mL bolus of lactated Ringer’s solution and an intravenous bolus of 100 μg of phenylephrine, and his blood pressure stabilizes. The anesthesiologist places an arterial line and advises the surgeon that he may proceed with the operation. After peritoneal insufflation with carbon dioxide (CO ₂ ), the patient is placed in an extreme reverse Trendelenburg (head-up) position. The blood pressure suddenly drops below 60 mm Hg, and then the arterial line waveform becomes flat and there is no palpable carotid pulse. Breath sounds are present bilaterally and equal. The electrocardiogram (ECG) tracing initially shows normal sinus rhythm but rapidly progresses to sinus bradycardia with ST segment depression. Blood pressure and ECG return to normal after intravenous administration of 1 mg of epinephrine and 1000 mL of crystalloid solution, immediate deflation of the abdomen, and placing the patient in Trendelenburg (head-down) position. However, the anesthesiologist and the surgeon decide to cancel the case and submit the patient to a thorough cardiac workup to rule out a coronary event.