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Unexpected surgical difficulties leading to hemorrhage and gas embolus during laparoscopic donor nephrectomy: a case report

[Difficultés chirurgicales inattendues conduisant à une hémorragie et à une embolie gazeuse pendant une néphrectomie laparoscopique chez un donneur : une étude de cas]

Kenneth Martay, MD^*, Greg Dembo, MD^*, Youri Vater, MD PhD^*, Kevin Charpentier, MD, Adam Levy, MD, Ramasamy Bakthavatsalam, MD and Peter R. Freund, MD^*

^* From the Department of Anesthesiology,
and the Department of Surgery, University of Washington Medical Center, Seattle, Washington, USA.

Address correspondence to: Dr. Kenneth Martay, Department of Anesthesiology, University of Washington Medical Center, P.O. Box 356 540, 1959 NE Pacific Street, Seattle, Washington 98195-6540, USA. Phone: 206-598-4260; Fax: 206-598-4544; E-mail: kmartay{at}u.washington.edu

Purpose: To report the case of a laparoscopic donor nephrectomy in which the preoperative evaluation of the patient gave no indication of the surgical difficulties that were encountered intraoperatively, resulting in substantial bleeding, a suspected gas embolism, and emergency conversion of the procedure from laparoscopic to open donor nephrectomy.

Clinical features: A 59-yr-old man – height: 175 cm, weight: 85.5 kg, American Society of Anesthesiologists physical status I – presented as kidney donor for laparoscopic donor nephrectomy. He was healthy, on no medication, and had no previous abdominal surgery or diseases of the urinary tract. The preoperative computed tomography (CT) scan evaluation of his kidneys confirmed this by reporting a normal bilateral renal and renal vascular anatomy. In contradiction to the preoperative CT scan findings, the surgeon discovered abnormalities in the operative field. This included extensive scarring surrounding the left kidney, adenopathy near the right hilum, and a large branch lumbar vein entering the renal vein. The large branch lumbar vein was clipped but the clips dislodged, causing significant blood loss, and a suspected gas embolus. The procedure was converted to an emergency open donor nephrectomy. Postoperatively the patient made a full recovery.

Conclusion: Laparoscopic donor nephrectomies, though usually performed on healthy individuals, have their pitfalls, and complications during this procedure can be sudden and serious. As shown in this case, although CT scan results are regarded as reliable, they can be misleading. As an anesthetic precaution for possible gas emboli during laparoscopic procedures, nitrous oxide should be avoided and the patient be ventilated with 100% oxygen.