Finding into death of Daryl Wayne Nankervis

64y · Male·Ischaemic bowel and spleen infarction secondary to occlusion of splenic artery and superior mesenteric artery by surgical clips complicating laparoscopic and open nephrectomy for renal cell carcinoma

A 64-year-old man died from bowel and spleen infarction caused by surgical clips incorrectly placed on the splenic and superior mesenteric arteries during laparoscopic nephrectomy for renal cell carcinoma. The surgeon misidentified major blood vessels in the setting of extensive fibrotic tissue around the kidney. Although the surgeon converted to open surgery, he placed clips on wrong vessels in both approaches. Post-operatively, the patient had fever but initial investigations were negative; he appeared well at morning review but collapsed suddenly at midday. The surgeon acknowledged the error and admitted he should have converted to open surgery sooner given the anatomical difficulties. The coroner recommended detailed post-operative notes documenting surgical complexities to enable appropriate monitoring. This case highlights the importance of recognising technical difficulty early, considering conversion to safer approaches, and ensuring thorough post-operative documentation and vigilance.