Background and aims We aim to describe the anesthetic management of a patient with severe obesity and chronic obstructive pulmonary disease scheduled for laparoscopic radical nephrectomy due to renal mass.

Methods A 62-year-old man with severe obesity (BMI 52,4 Kg/m²) and obstructive pulmonary disease was scheduled for a laparoscopic nephrectomy. Because his pulmonary function was impaired, combined spinal-epidural anesthesia was selected. Epidural catheter was inserted at T6-T7 intervertebral space and spinal anesthesia was performed at T9-T10 intervertebral space with 3 ml of 0.5% levobupivacaine (15 mg) plus 1 mg of midazolam. The patient received one bolus of 3 mL 0.5% levobupivacaine (15 mg) plus 25 mcg of fentanyl via the epidural catheter at 1 hour after entering the operating room, followed by a continuous epidural infusion of 0,5% levobupivacaine at 5 mL/hr. Propofol and Remifentanil were administered intravenously to achieve the desired level of sedation.

Results A transperitoneal laparoscopic left kidney nephrectomy was performed without complications and the patient was transferred in an alert and comfortable condition to the ICU for close monitoring.

Conclusions Although laparoscopic nephrectomy is usually performed under general anesthesia, in a complex patient with severe obesity and chronic obstructive pulmonary disease, we conclude that combined spinal-epidural anesthesia can be considered a safe and effective approach.