Persistent cardiopulmonary instability potentially caused by right ventricular compression from a laparoscopic retractor during Heller myotomy: a case report

Persistent intraoperative cardiopulmonary instability during laparoscopic surgery is commonly attributed to atelectasis, aspiration, or carbon dioxide embolism.Mechanical compression of the right ventricle (RV) by intra-abdominal retractors is a less recognized mechanism and has not been previously characterized during laparoscopic Heller myotomy.A 50-year-old man with type I achalasia underwent laparoscopic Heller myotomy with Dor fundoplication.Approximately 10-30 minutes after incision, coincident with retractor positioning, oxygen reserve index (ORi) declined from 0.53 to 0.00, perfusion index decreased to one-third of baseline, and pleth variability index (PVi) increased by 27%, without changes in respiratory mechanics or electrocardiogram.Refractory sinus tachycardia and progressive metabolic acidosis (lactate 2.3 to 6.0 mmol/L) developed.Intermittent pneumoperitoneum desufflation showed no improvement.After retractor removal, ORi recovered to 1.00, and PVi decreased to 4. The findings suggest suspected retractor-induced RV compression causing persistent cardiopulmonary instability during laparoscopic Heller myotomy.