Coroner's Finding: MCSHANE Robert Ian

66y · Male·Multi-system failure and ischaemic gut after left nephrectomy complicated by massive haemorrhage and vascular grafting

A 66-year-old man died from multi-system failure and ischaemic bowel following laparoscopic left nephrectomy complicated by massive haemorrhage and vascular injury. During surgery for renal carcinoma, the surgeon attempted to control bleeding from an unidentified vessel using a laparoscopic stapler without adequate visualisation of the stapler tips. This resulted in transection of the abdominal aorta and right renal artery. Although vascular surgeons successfully repaired the aorta, the patient developed irreversible intestinal ischaemia. The coroner found that the surgeon's decision to use the stapler without clear visualisation of critical vessels was an error of judgment. Key lessons include: never deploy staplers without complete visualisation of contents in the jaws, consider earlier conversion to open surgery when laparoscopic bleeding cannot be controlled, and ensure adequate surgical assistance and senior support for complex laparoscopic cases.