a 50-year - old female patient was scheduled to undergo a laparoscopic - assisted vaginal hysterectomy . the pre - operative chest x - ray , electorocardiogram ( ecg ) , complete blood count , blood chemistry , electrolyte were within the normal limits . the patient received premedication with midazolam 2 mg and glycopyrrolate 0.2 mg via an intramuscular injection 30 minutes before surgery . anesthesia and muscle relaxation was induced with propofol 100 mg and rocuronium 50 mg , respectively . after anesthesia induction , a chest band was applied to the patient at the level of the xyphoid process and inframammary fold . a cloth band , 5 cm in width and 120 cm in length , with velcro tape at both tips was made by the authors ( fig . chest band compression was achieved by 5 cm reduction of the patient chest circumference ( fig . intraoperative monitoring included ecg , noninvasive blood pressure ( nibp ) , pulse oxymetry , and capnogram . the number of surgical ports was 3 and the co2 gas pressure was 15 mmhg . the duration of the operation and co2 insufflation was 145 minutes and 86 minutes , respectively . after surgery , crepitus was palpated over the surgical field to the level of the chest band . co2 subcutaneous emphysema was not observed beyond the chest band according to the post operative chest x - ray ( fig . 3 ) . there were no complications related to the chest band , such as pressure sores and ventilatory difficulties . a 54-year - old female patient was scheduled to undergo a laparoscopic - assisted radical vaginal hysterectomy . after anesthesia induction , a chest band was placed on the patient in a similar manner to case 1 . intraoperative monitoring included the ecg , arterial blood pressure , nibp , central venous pressure , pulse oximetry and capnogram . the number of surgical ports and co2 gas pressure was 4 and 15 mmhg , respectively . the duration of surgery and co2 insufflation was 450 minutes and 405 minutes , respectively . after surgery , palpation revealed crepitus over the surgical field to the level of the chest band . co2 subcutaneous emphysema beyond the chest band was not observed by postoperative chest x - ray ( fig . a 50-year - old female patient was scheduled to undergo a laparoscopic - assisted vaginal hysterectomy . the pre - operative chest x - ray , electorocardiogram ( ecg ) , complete blood count , blood chemistry , electrolyte were within the normal limits . the patient received premedication with midazolam 2 mg and glycopyrrolate 0.2 mg via an intramuscular injection 30 minutes before surgery . anesthesia and muscle relaxation was induced with propofol 100 mg and rocuronium 50 mg , respectively . after anesthesia induction , a chest band was applied to the patient at the level of the xyphoid process and inframammary fold . a cloth band , 5 cm in width and 120 cm in length , with velcro tape at both tips was made by the authors ( fig . chest band compression was achieved by 5 cm reduction of the patient chest circumference ( fig . intraoperative monitoring included ecg , noninvasive blood pressure ( nibp ) , pulse oxymetry , and capnogram . the number of surgical ports was 3 and the co2 gas pressure was 15 mmhg . the duration of the operation and co2 insufflation was 145 minutes and 86 minutes , respectively . after surgery , crepitus was palpated over the surgical field to the level of the chest band . co2 subcutaneous emphysema was not observed beyond the chest band according to the post operative chest x - ray ( fig . 3 ) . there were no complications related to the chest band , such as pressure sores and ventilatory difficulties . a 54-year - old female patient was scheduled to undergo a laparoscopic - assisted radical vaginal hysterectomy . she had no underlying disease . after anesthesia induction , a chest band was placed on the patient in a similar manner to case 1 . intraoperative monitoring included the ecg , arterial blood pressure , nibp , central venous pressure , pulse oximetry and capnogram . the number of surgical ports and co2 gas pressure was 4 and 15 mmhg , respectively . the duration of surgery and co2 insufflation was 450 minutes and 405 minutes , respectively . after surgery , palpation revealed crepitus over the surgical field to the level of the chest band . co2 subcutaneous emphysema beyond the chest band was not observed by postoperative chest x - ray ( fig . it includes the following : reduced venous return from the lower extremities , reduced cardiac output and index , marked reduction in functional residual capacity , increased peak airway pressure , ventilation perfusion mismatch and increased alveolar / arterial o2 gradient . a patient undergoing laparoscopic surgery with co2 pneumoperitoneum is at risk of arrhythmia , hypercarbia , atelectasis , pneumothorax , pneumomediastinum and subcutaneous emphysema . co2 significant insufflation of co2 into the injured subcutaneous tissues can cause extensive co2 subcutaneous emphysema and substantial co2 absorption . extensive co2 subcutaneous emphysema causes hypercarbia , an increase in arterial co2 pressure , and an increase in the plasma catecholamine level . if the hypercarbia is not corrected , it can lead to severe respiratory acidosis and cardiovascular suppression . if extraperitoneal co2 insufflation occurs , co2 spreads to the subcutaneous tissue layer of entire body because there is no limitation in the expansion of the gas within the subcutaneous layer . however , in the case of intraperitoneal co2 insufflation , limited space can cause an increase in abdominal pressure , which can compress the capillary vessels . suppression of capillary circulation causes a decrease in co2 diffusion . diffusion due to intraperitoneal co2 insufflation causes an increase in co2 uptake until 15 - 20 minutes and becomes steady , whereas extraperitoneal co2 insufflation causes an increase in co2 uptake for the entire insufflation time . wolf et al .   reported that if co2 subcutaneous emphysema is present , co2 uptake can increase to 113% , compared to the 26% increase in subcutaneous emphysema absence . more rapid co2 absorption occurs if there is an increase in the co2 subcutaneous emphysema field . the risk factors for co2 subcutaneous emphysema during laparoscopy include a maximum petco2 of 50 mmhg or greater , the use of six or more surgical ports , surgery time more than 200 minutes and patient 's age over 65 years . most reports of extensive co2 subcutaneous emphysema describe the treatments of emphysema , not prevention . based on the idea that co2 subcutaneous emphysema spreads through subcutaneous tissue layer , the authors made a cloth band , 5 cm in width and 120 cm in length , with velcro tape to create continuous pressure on the subcutaneous tissue layer to prevent the expansion of co2 subcutaneous emphysema . the chest band was applied to the xyphoid process and inframammary fold level by 5 cm to reduce the length from the patient 's band level circumference . there were no complications with the application of a chest band , such as skin necrosis or ventilation problems . from these two case reports , it is presumed that a chest band has a protective effect from co2 subcutaneous emphysema expansion . the restriction of co2 subcutaneous emphysema expansion may reduce the co2 absorption rate and delay hypercarbia and respiratory acidosis . however , more study will be needed to determine the proper chest band pressure and complications .
co2 subcutaneous emphysema is one of the complications of laparoscopic surgery using co2 gas . during laparoscopic surgery 
 , co2 gas can spread to the entire body surface through the subcutaneous tissue layer . 
 extensive co2 subcutaneous emphysema results in hypercarbia and acute respiratory acidosis . 
 hypercarbia and acidosis can lead to decreased cardiac contractility and arrhythmia . 
 a cloth band , 5 cm in width and 120 cm in length , was made with velcro tape at both tips , and placed on the patient 's xyphoid process level and inframammary fold to prevent co2 subcutaneous emphysema . 
 this report describes two successful cases using a chest band to prevent the expansion of co2 subcutaneous emphysema .