Pulmonary Gas Embolism During Robot-Assisted Partial Nephrectomy: Experiences, Current Trends, and Important Cautions in Japan.

In Japan, nine gas embolisms related to robot-assisted partial nephrectomy (RAPN)-including fatal cases-have been reported, all with a retroperitoneal approach, predominantly at 15 mmHg intra-abdominal pressure using gasketless cannulas. At our facility, a gas embolism occurred during retroperitoneal RAPN for an 18 × 14-mm left renal cell carcinoma. During resection, intra-abdominal pressure was maintained at 15 mmHg with positive end-expiratory pressure deactivated. Seven minutes later, percutaneous oxygen saturation fell to 89%, accompanied by a decrease in end-tidal carbon dioxide, leading to a diagnosis of pulmonary gas embolism. Postoperative plain computed tomography revealed a mirror image of CO2 from the inferior vena cava to the left femoral vein. The retroperitoneal approach, high intra-abdominal pressure, and use of gasketless cannulas are considered risk factors for gas embolism. Prevention requires understanding these factors and setting appropriate intra-abdominal pressures.