Hours on the Operating Table: When Kidney Surgery Triggers Dangerous Muscle Breakdown

A routine operation nearly turned catastrophic. A 53-year-old man with Class II obesity arrived at the hospital for a robotic laparoscopic radical nephrectomy, the surgical removal of a cancerous left kidney along with nearby lymph nodes. The procedure itself went smoothly: the kidney was extracted without bleeding, blood loss was modest at 250 milliliters, and the surgical team worked with textbook precision. But the moment the anesthesia wore off, the patient was gripped by severe, unrelenting pain in his right buttock, a symptom that had nothing to do with the kidney that had just been removed. What clinicians discovered next reveals a rare but serious hazard lurking in the geometry of modern surgery: the way a body is positioned on the operating table for hours can quietly crush its own muscle tissue from the inside.

The case, published in Clinical Case Reports, documents perioperative rhabdomyolysis, a condition in which skeletal muscle fibers break down and dump their intracellular contents into the bloodstream. The mechanism is deceptively simple and physiologically brutal. When muscle cells are compressed or deprived of blood flow for extended periods, their membranes fail, calcium floods into the cells, and ATP reserves are depleted. The result is irreversible necrosis of muscle fibers and the release of myoglobin, potassium, phosphate, and creatine kinase, an enzyme that serves as the biochemical fingerprint of muscle destruction. In the circulation, these liberated molecules can trigger dangerous electrolyte disturbances, including hyperkalemia and hyperphosphatemia, while the myoglobin filtered by the kidneys can obstruct renal tubules, poison them directly, and constrict renal vessels, all of which threaten acute kidney injury.

This patient carried nearly every established risk factor in the literature. He stood 188 centimeters tall and weighed 136 kilograms, giving him a body mass index of 38.5, well within Class II obesity. His medical history included Type 2 diabetes, hypertension, and a 36-pack-year smoking history, and his American Society of Anesthesiologists physical status was rated 3, indicating severe systemic disease. Obesity, male sex, prolonged operative times, and lateral decubitus positioning, lying on one’s side, have all been consistently identified as risk factors in reports of laparoscopic renal surgery. A large national cohort study estimated the incidence of rhabdomyolysis after major urologic surgery at roughly 0.1 percent, rare enough that many surgical teams will never encounter it, but common enough to demand vigilance in high-risk patients.

The operation lasted five hours and fifteen minutes, and that duration may have been decisive. The patient was placed in the right flank position, the standard posture for left-sided kidney surgery, with pressure-relieving padding at joints and pressure points that were reassessed every fifteen minutes. Even so, his dependent right gluteal muscles were compressed under his own body weight for the entire procedure. Prior research has identified a three-hour operative duration as a critical threshold for rhabdomyolysis risk in obese patients undergoing laparoscopic nephrectomy, with experts recommending early serum creatine kinase measurement on the day of surgery for such cases. This patient’s procedure far exceeded that threshold, and no intraoperative repositioning was performed.

The laboratory findings on the first postoperative day were striking. Serum creatine kinase measured 53,067 units per liter, roughly 180 times the upper limit of the normal reference range of 51 to 298 units per liter. Serum myoglobin was elevated at 1,625 nanograms per milliliter against a reference value below 91. For context, levels above 5,000 units per liter are associated with increased kidney injury risk, and values exceeding 15,000 units per liter are classified as severe rhabdomyolysis. The peak value here was comparable to a previously reported case of rhabdomyolysis after prolonged laparoscopic radical nephrectomy, in which the first postoperative day creatine kinase reached 51,050 units per liter. Notably, the patient’s creatinine remained essentially normal at 1.19 milligrams per deciliter, and a review of the anesthesia record found no episodes of prolonged or untreated hypotension, ruling out low blood pressure as a significant contributor.

Imaging added a layer of diagnostic complexity that illustrates how challenging these cases can be. A CT scan revealed an enlarged right gluteus medius muscle consistent with an intramuscular hematoma, with fluid and stranding tracking into the right posterior thigh. Yet an ultrasound performed immediately afterward showed no hematoma or fluid collection at all. Compartment pressure measured with a Stryker needle in the upper outer gluteal quadrant was only mildly elevated at 12 millimeters of mercury. The clinical team acknowledged that the CT abnormality and the biochemical evidence of rhabdomyolysis may not have represented the same pathological process, and that the exact timing and mechanism of the suspected hematoma could not be determined. Nevertheless, the overall picture, acute gluteal pain after prolonged surgery combined with dramatically elevated muscle enzymes, pointed firmly to perioperative rhabdomyolysis as the principal diagnosis.

Treatment began immediately. The patient received aggressive intravenous hydration with 100 milliequivalents of sodium bicarbonate in one liter of 0.45 percent sodium chloride, continued at 200 milliliters per hour through the second postoperative day, following an institutional practice aimed at urinary alkalinization. The physiology behind this approach is well understood: once muscle injury occurs, fluid shifts from the intravascular space into damaged tissue, creating a so-called third space that contributes to hypovolemia and renal ischemia. Hypovolemia further restricts renal blood flow through sympathetic activation, vasoconstrictor release, and nitric oxide degradation. Early volume resuscitation preserves renal perfusion and helps flush myoglobin through the kidneys before it can cause tubular obstruction and toxicity. Interestingly, the authors note that adjunctive therapies such as mannitol and sodium bicarbonate, long mainstays of rhabdomyolysis management, are now viewed with skepticism, as recent evidence does not support their routine use; current practice emphasizes early volume expansion and avoiding agents that reduce renal blood flow.

The recovery was reassuringly rapid. Serial monitoring showed creatine kinase falling from 53,067 to 17,712 units per liter later on the first postoperative day, then to 11,011 by day two. Creatinine rose transiently to 1.38 milligrams per deciliter before settling back to 1.18. Calcium dipped to 8.0 milligrams per deciliter on day two, a predictable consequence of injured myocytes sequestering calcium, with the caveat that clinicians avoid calcium replacement unless hyperkalemia with electrocardiographic changes is present, because rebound hypercalcemia can occur during recovery as calcium is released back into circulation. The patient was discharged on postoperative day three without ever requiring renal replacement therapy, a fortunate outcome given that other reported cases have progressed to hemodialysis despite aggressive hydration. At one-month follow-up, his creatine kinase had normalized to 72 units per liter, creatinine was 1.27, and calcium had rebounded to 10.9 milligrams per deciliter.

The broader lesson extends well beyond a single case. As minimally invasive robotic and laparoscopic techniques enable ever longer and more complex operations, surgeons and anesthesiologists are increasingly confronting complications rooted not in the surgery itself but in the stillness it demands. Preventive strategies include optimizing pressure distribution with careful padding, minimizing flank flexion, and periodically repositioning the patient during lengthy procedures, alongside postoperative monitoring of creatine kinase and renal function to catch muscle injury early. For patients who combine obesity with anticipated operative times beyond three hours in the lateral decubitus position, the authors suggest that early enzyme measurement on the day of surgery may allow timely recognition before kidney damage occurs. This case is a vivid reminder that in modern surgery, the most dangerous forces are sometimes not the scalpel or the robot, but gravity and time acting silently on a body held motionless under anesthesia.

Subject of Research: Perioperative rhabdomyolysis following prolonged laparoscopic radical nephrectomy in the lateral decubitus position

Article Title: Perioperative Rhabdomyolysis Following Prolonged Laparoscopic Radical Nephrectomy in the Lateral Decubitus Position

Article References: Dow, M., Srinivasan, A., & Ayad, S. (2026). Perioperative Rhabdomyolysis Following Prolonged Laparoscopic Radical Nephrectomy in the Lateral Decubitus Position. Clinical Case Reports, 14(10), Article e73640. https://doi.org/10.1002/ccr3.73640

Image Credits: AI Generated

DOI: 10.1002/ccr3.73640

Keywords: rhabdomyolysis, laparoscopic nephrectomy, lateral decubitus position, creatine kinase, myoglobin, acute kidney injury, obesity, patient positioning, perioperative complications, robotic surgery, gluteal muscle injury, case report