CO2 embolism can complicate transanal total mesorectal excision



Carbon dioxide (CO2) embolism is a rare but potentially devastating complication of minimally invasive abdominal and retroperitoneal surgery. Characterized by a decrease in end-tidal CO2 (ETCO2) and oxygen saturation (SpO2), CO2 emboli can cause rapid intraoperative hypotension and cardiovascular collapse. Transanal total mesorectal excision (taTME) is a novel surgical approach for rectal resection, which requires high flow CO2 insufflation in a low volume operative field. In this setting, the incidence of CO2 embolism is unknown; we evaluate three cases of intraoperative CO2 embolism that occurred during the transanal portion of the TME dissection.


All taTME cases from December 2014 to March 2018 at a single institution were reviewed. Cases of CO2 embolism were identified intraoperatively and characterized using the operative reports and anesthesia records. The transanal/pelvic insufflation included a targeted pressure of 15 mm Hg, high flow and high smoke evacuation. Physiologic derangements and management of these instances were analyzed. The postoperative course was evaluated and any complications were noted.


A total of 80 taTME were performed for benign and malignant disease. Three patients (4%) developed intraoperative evidence of CO2 embolism. Each instance occurred during the transanal portion of the dissection. Physiologic changes were marked by abrupt decrease in end-tidal ETCO2, SpO2, and blood pressure (BP). Management included immediate release of pneumopelvis, hemodynamic support with crystalloid or vasopressors, and placement of the patient in the Trendelenburg position with left side down. Within 10 min of the acute event, all patients had return of ETCO2, SpO2, and BP to pre-event levels. There were no intraoperative or postoperative sequelae including arrhythmia, myocardial infarction, stroke or death. No cases required conversion to open.


During taTME, rare CO2 emboli may occur in the setting of venous bleeding during pneumopelvis, causing sudden, transient cardiovascular instability. Immediate recognition of rapid decrease in ETCO2, SpO2, and BP should be followed by desufflation of pneumopelvis, patient positioning in Trendelenburg and left lateral decubitus, and hemodynamic support. Increased awareness of this potential complication and maintaining a high index of suspicion will lead to preparedness of the anesthesia and surgery teams.

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  1. 1.

    Sylla P, Rattner DW, Delgado S, Lacy AM (2010) NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 24(5):1205–1210

    Article  Google Scholar 

  2. 2.

    Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, Moran B, Hanna GB, Mortensen NJ, Tekkis PP (2017) TaTME Registry Collaborative. Transanal total mesorectal excision: international registry results of the first 720 cases. Ann Surg 266(1):111–117

    Article  Google Scholar 

  3. 3.

    Ma B, Gao P, Song Y, Zhang C, Zhang C, Wang L, Liu H, Wang Z (2016) Transanal total mesorectal excision (taTME) for rectal cancer: a systematic review and meta-analysis of oncological and perioperative outcomes compared with laparoscopic total mesorectal excision. BMC Cancer 16:380

    Article  Google Scholar 

  4. 4.

    Rouanet P, Mourregot A, Azar CC, Carrere S, Gutowski M, Quenet F, Saint-Aubert B, Colombo PE (2013) Transanal endoscopic proctectomy: an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis. Dis Colon Rectum 56(4):408–415

    Article  Google Scholar 

  5. 5.

    Ratcliffe F, Hogan AM, Hompes R (2017) CO(2) embolus: an important complication of TaTME surgery. Tech Coloproctol 21(1):61–62

    CAS  Article  Google Scholar 

  6. 6.

    Lucas WJ (1987) How to manage air embolism. In: Vaughn RW (ed) Problems in anesthesia. JB Lippincott Co., Philadelphia, pp 228–252

    Google Scholar 

  7. 7.

    Marino PL, Sutin KM (1998) The ICU book. Williams & Wilkins, Baltimore

    Google Scholar 

  8. 8.

    Gordy S, Rowell S (2013) Vascular air embolism. Int J Crit Illn Inj Sci 3(1):73–76

    Article  Google Scholar 

  9. 9.

    Atallah S, Gonzalez P, Chadi S, Hompes R, Knol J (2017) Operative vectors, anatomic distortion, fluid dynamics and the inherent effects of pneumatic insufflation encountered during transanal total mesorectal excision. Tech Coloproctol 21(10):783–794

    CAS  Article  Google Scholar 

  10. 10.

    Natal BL, Doty CI (2018) Venous air embolism treatment and management. Available at Accessed April 2018

  11. 11.

    Hong JY, Kim JY, Choi YD, Rha KH, Yoon SJ, Kil HK (2010) Incidence of venous gas embolism during robotic-assisted laparoscopic radical prostatectomy is lower than that during radical retropubic prostatectomy. Br J Anaesth 105(6):777–781

    CAS  Article  Google Scholar 

  12. 12.

    Phillips J, Keith D, Hulka J, Hulka B, Keith L (1976) Gynecologic laparoscopy in 1975. J Reprod Med 16:105–117

    CAS  PubMed  Google Scholar 

  13. 13.

    Hynes SR, Marshall RL (1992) Venous gas embolism during gynaecological laparoscopy. Can J Anaesth 39:748–749

    CAS  Article  Google Scholar 

  14. 14.

    Hong JY, Kim WO, Kil HK (2010) Detection of subclinical CO2 embolism by transesophageal echocardiography during laparoscopic radical prostatectomy. Urology 75:581–584

    Article  Google Scholar 

  15. 15.

    Park EY, Kwon JY, Kim KJ (2012 May) Carbon dioxide embolism during laparoscopic surgery. Yonsei Med J 53(3):459–466

    Article  Google Scholar 

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Correspondence to C. R. Harnsberger.

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Harnsberger, C.R., Alavi, K., Davids, J.S. et al. CO2 embolism can complicate transanal total mesorectal excision. Tech Coloproctol 22, 881–885 (2018).

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  • Transanal total mesorectal excision
  • Complications
  • Carbon dioxide embolism