this complication usually occurs during abdominal aortic surgery and is an unusual complication following live donor nephrectomy . live kidney donors are healthy individuals who willingly undergo major surgery to improve the well - being of another individual . therefore , it is of utmost importance to minimize the risks of this procedure and thus maximize donor safety . a 39-year - old mediterranean female with a bmi of 26 , underwent an elective , living - related , transperitoneal left - sided totally robot - assisted donor nephrectomy using the da vinci surgical system . donor nephrectomy was performed by a transplant surgeon and assisted by a second transplant surgeon , as described elsewhere [ 2 , 3 ] . briefly , the procedure was performed with the da vinci surgical system s using three arms with a fenestrated bipolar forceps ( endowrist bipolar cautery instrument ; intuitive surgical , sunnydale , usa ) in arm 1 , a monopolar cautery hook ( endowrist monopolar cautery instrument ; intuitive surgical , sunnydale , usa ) to dissect structures in arm 2 and the camera ( 3d vision system 12 mm 30 endoscope ; intuitive surgical , sunnydale , usa ) in arm 3 . after full exposure of the kidney and vascular structures , a pfannenstiel incision was made and an endo - bag ( endocatch ; us surgical , norwalk , usa ) was introduced into the abdomen . subsequently , the ureter was clipped and divided with scissors , and the renal artery and the vein were transected using an endoscopic stapler ( endogia ; us surgical , norwalk , usa ) . the kidney was then placed in the endobag and extracted through the pfannenstiel incision . before removing all trocars , the renal bed and vascular stumps were inspected using the da vinci , and intra - abdominal hemostasis was performed with the fenestrated bipolar forceps . the operation field was found to be dry after which all incisions were closed intracutaneously . postoperatively , the patient was placed on dipidolor patient - controlled analgesia combined with paracetamol . during the postoperative recovery she was discharged at postoperative day 3 with a normal appetite and no wound problems . on postoperative day 11 , she visited the outpatient clinic for a follow - up visit and the nausea was completely gone . however , she noted abdominal pain located on the right side near the iliac crest and reported two episodes of hematuria . laboratory results showed a decreased c - reactive protein ( crp ) level and normal leukocyte count . on postoperative day 19 , the patient noted bright red fluid leakage from the pfannenstiel incision without any further symptoms and contacted the nurse practioner . it was decided that she would visit the outpatient clinic if the leakage would worsen or other complaints would emerge . on postoperative day 29 , the patient visited the outpatient clinic for her scheduled 1-month postoperative follow - up visit . she still experienced pain in her abdomen which was mildly controlled with anti - analgesia . the pain progressed when she laid on her right or left side and , at night , her abdomen was more distended than usual . on physical examination , she had a distended abdomen , with tenderness on palpation on the right and the left side , and below the umbilicus , with a shifting dullness on percussion during movement . an abdominal ultrasonography showed intraperitoneal fluid in all four quadrants of the abdomen and a diagnostic paracentesis demonstrated yellow fluid with a lipid aspect , suspected of being chylous ascites and confirmed by biochemical analysis showing positive triglycerides of 57.98 mmol / l . she was admitted to the hospital for drainage and a medium - chain triglyceride - based diet was started . on day 4 the medium - chain triglyceride - based diet was continued for a total of 4 weeks after which a second abdominal ultrasonography was done , which showed no fluid in the abdomen . in this case report , we describe the first reported complication of chylous ascites after total robot - assisted donor nephrectomy . this complication is more common in major oncological surgical procedures , where lymph nodes are often resected . therefore , from an oncological point of view these patients often casually accept this complication . nevertheless , healthy live kidney donors are different from patients who undergo extensive dissection damaging lymphatic vessels necessitating postoperative treatment . in over three decades , > 1500 live donor nephrectomies have been performed at our centre and never before have we encountered a case of postoperative chylous ascites after a donor nephrectomy . a review of the literature resulted in a total of 56 reported cases of chylous ascites after donor nephrectomy ( supplement 1 ) . a huge contrast has been compared with the thousands of live donor nephrectomies that have been published over the years . the occurrence of chylous ascites is low and the expectation is that this is an underestimation . there is no clear treatment pathway ; however , a median chain triglyceride diet combined with a therapeutic drain or octreotide seems to be the first step . we could not identify any other reported cases of chylous ascites after robot - assisted donor nephrectomy [ 2 , 47 ] . during a robot - assisted donor nephrectomy , it is not necessary to dissect the lymfatic tissues around the aorta and the origo of the real artery . larger lymphatics around the renal vessels are either clipped or sealed by modern energy devices . in our case , a fenestrated bipolar forceps and a monopolar cautery hook were used for dissection and sealing . however , with monopolar energy , although control the lymphatics for a short time , necrosis can occur later on leading to leakage of large amount of chyle . the complication is often diagnosed after a few weeks , causing a delay in treatment . fortunately , the complication can be successfully treated with conservative measures within a few weeks as demonstrated in this case .
we present the first case report of chylous ascites following total robot - assisted donor nephrectomy . 
 a 39-year - old female underwent a transperitoneal left - sided total robot - assisted donor nephrectomy . 
 the procedure was uneventful and the patient was discharged without any symptoms . at postoperative day 29 , 
 the patient presented with abdominal pain , nausea and a distended , painful abdomen with shifting dullness . 
 she was diagnosed with chylous ascites by ultrasonography and puncture analysis , and treated with therapeutic drainage and dietary restriction . 
 after 4 weeks , she was free of symptoms . 
 the occurrence of this complication is rare after donor nephrectomy . 
 fortunately , the complication can be successfully treated within a few weeks with minimal discomfort for the patient as demonstrated in this case . 
 it is of utmost importance to minimize the risks and limit discomfort for live kidney donors who willingly undergo major surgery to improve the well - being of another individual .