Successive perioperative management of laparoscopic liver resection in the reverse Trendelenburg position for a patient with Fontan physiology: a case report

BACKGROUND: Laparoscopic surgery for a patient with Fontan physiology is challenging because pneumoperitoneum and positive pressure ventilation could decrease venous return and the accumulated partial pressure of arterial carbon dioxide (PaCO(2)) could increase pulmonary vascular resistance, which might lead to disruption of the hemodynamics. CASE PRESENTATION: A 25-year-old man with Fontan physiology was scheduled to undergo laparoscopic liver resection for Fontan-associated liver disease (FALD) with noninvasive monitoring of cardiac output (CO) by transpulmonary thermodilution in addition to transesophageal echocardiography. The abdominal air pressure was maintained low, and we planned to switch to open abdominal surgery promptly if hemodynamic instability became apparent because of the accumulated PaCO(2) or postural change. Consequently, the pneumoperitoneum had limited influence on circulatory dynamics, but central venous pressure significantly decreased with postural change to the reverse Trendelenburg position. Laparoscopic liver resection for FALD was performed successfully with no significant changes in CO and central venous saturation. CONCLUSIONS: With strict circulation management, laparoscopic surgery for a patient with Fontan physiology can be performed safely. Comprehensive hemodynamic assessment by noninvasive transpulmonary thermodilution can provide valuable information to determine the time for shift to open abdominal surgery.