Laparoscopic Nephrectomy Donor Death Due to Cerebral Gas Embolism in a Specialized Transplant Center: Risk Zero Does Not Exist

The shortage of cadaver donors and increasing renal transplant waiting lists have made live donor nephrectomy an option. The first laparoscopic (LSC) live donor nephrectomy was performed by Ratner et al. in 1995 (1). LSC donor nephrectomy is widely accepted and is being performed in specialized centers. In the following, we report a fatal case of gas embolus in a LSC donor nephrectomy patient after an injury to the right phrenic vein. A 34-year-old female patient underwent a LSC donor right nephrectomy in a tertiary care center with a large experience in laparoscopy and renal transplantation. During the mobilization of the liver, injury to the right phrenic vein occurred. The vein was ligated laparoscopically. Blood loss was estimated at 1,200 cc. The systolic blood pressure was between 60 and 70, O2 saturation was maintained at 100%, heart rate was normal, and end tidal PC02 decreased from 37 to 32. The blood pressure remained low for 15 min. Hemoglobin was 84. A unit of packed red cells was given. The rest of the surgery continued without further complications. The patient remained hemodynamically stable. After the patient was moved to the recovery room, writhing movements of the trunk and extremities were noticed. A chest radiograph was normal. Heart rate and blood pressure remained stable. An EEG showed diffuse abnormal epileptic activity suggesting cerebral anoxia. The CT scan of the head was negative. A cardiac ultrasound was normal. At this point, it was thought that the patient had suffered a cerebral gas embolism. Three hyperbaric oxygen treatments were undertaken. A repeat CT scan done 2 days later showed diffuse cerebral edema. She died shortly afterwards and an autopsy was not done. Complications specific to LSC right donor nephrectomy have been reported to include liver lacerations (5%), bleeding from vena cava (1%), and 9% graft loss because of vascular thrombosis (2–4). There are no reported cases of fatal gas embolism in donor nephrectomies. There is one report of this compli-cation in a LSC left donor nephrectomy where the patient survived after aggressive resuscitation (5). We believe that our patient suffered an unrecognized gas embolism through an injured phrenic vein. Gas embolus results in a sudden decrease of ETC02, hypotension, desaturation, and a mill-wheel murmur. Diagnosis can also be made by using transesophageal echocardiogram. Postoperative manifestations include pulmonary edema and brain ischemia if the embolus goes into the arterial system by way of a patent foramen ovale or an AV malformation or fistula. When gas embolus is suspected, it is imperative that pneumoperitoneum be released and the patient be placed in Trendelenburg. The procedure should be converted to open. One hundred percent oxygen ventilation should be used (5). Although live donors help relieve organ shortage, major surgery in healthy patients is still ethically challenged. Gas embolism is a rare and fatal complication that surgeons and anesthetists should be aware of and be prepared to deal with. LSC donor nephrectomy patients should be informed of the potential dangers of the surgery. The risks should not be minimized. Therese Boghossian Margaret Henri Serge Dubé Yves Bendavid Michel Morin Department of General Surgery Université de Montréal Montréal, Québec