A valuable lesson from a case report of donor nephrectomy complication – managing internal hernia through an iatrogenic retroperitoneal defect: a case report

Introduction and Importance: An internal hernia through an iatrogenic retroperitoneal defect following open donor nephrectomy is an extremely uncommon but potentially life-threatening complication. Compared with laparoscopic procedures, this etiology is under-recognized in open surgery, and awareness is essential for timely diagnosis and prevention of bowel ischemia. Case presentation: A 54-year-old male living kidney donor developed acute small bowel obstruction on postoperative day 1 following open left donor nephrectomy; the retroperitoneal defect created during dissection was not closed. CT confirmed mid-jejunal closed-loop obstruction. Diagnostic laparoscopy identified a 10-cm mid-jejunal segment herniated through a 4–5 cm retroperitoneal defect with viable bowel. Laparoscopic reduction failed owing to gross luminal distension; open conversion achieved successful reduction without bowel resection, and the defect was closed with PD Synth 1-0 polydioxanone sutures. Clinical discussion: The temporal relationship between retroperitoneal dissection and early postoperative obstruction is the key diagnostic pointer. CT is the investigation of choice. Surgical repair, laparoscopic or open, is the only definitive treatment, with conversion being appropriate when distension impairs safe reduction. Routine defect closure at the index procedure is the principal preventive lesson. Conclusion: Three essential lessons emerge: (1) retroperitoneal and mesenteric defects must be formally closed at every donor nephrectomy; (2) early postoperative obstruction mandates CT evaluation and exclusion of an internal hernia; and (3) prompt reoperation, with a willingness to convert to open surgery, yields excellent outcomes. This case report has been prepared in accordance with the SCARE 2025 criteria.