Injection of methylene blue in the lungs during laparoscopic cholecystectomy

In a surgical setting, intraoperative methylene blue usage is a safe and effective technique in detecting gastric leak during laparoscopic abdominal surgery [1]. A Nasogastric (NG) tube is commonly used to empty the stomach and to monitor the occurrence of bowel occlusion after major abdominal surgery. The incidence of misplacement of NG tubes into the airways ranges between 0.3% and 15% [2] and is associated with significant morbidity and mortality [3]. A 68-year-old male patient presented to the operating room for scheduled laparoscopic cholecystectomy. After tracheal intubation and commencement of surgery, an 18 Fr. NG tube was inserted blindly through the nostril with no means of assessing its position. A solution of methylene blue was prepared and 240 ml were injected in the NG tube. Upon applying negative pressure suction on the NG, a noticeable change in airway pressure was noted and investigation through the use of fiber optic vision revealed the presence of bluish liquid in the bronchi. The NG tube was then re-inserted, the surgeon made the final confirmation of its proper placement within the stomach and the surgery continued uneventfully. Postoperative chest x-ray was suggestive of hypersensitivity pneumonitis and emphysema. Patient was first admitted to the intensive care unit where treatment was initiated, to be then transferred to the ward and later discharged on post-operative day three.