Laparoscopic resection for low rectal cancer in a patient with horseshoe kidney – Technical considerations to prevent iatrogenic injuries

Abstract

Horseshoe kidney (HSK) is a rare congenital malformation of the kidneys and is commonly associated with other anomalies of the renovascular and ureteropelvic systems. These anomalies present a surgical challenge, especially for surgeries involving the retroperitoneum. We present the case of a 56-year-old male patient with biopsy-proven rectal cancer who had completed neoadjuvant chemoradiation and was planned for curative resection. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis revealed the presence of an HSK. Reconstructed three-dimensional (3D) images of the renal vasculature revealed the presence of an accessory renal artery originating directly from the aorta and supplying the isthmus of the HSK without any other venous or ureteral anomalies. Laparoscopic abdominoperineal resection with total mesorectal excision was done without any untoward complications. The presence of HSK per se is not a contraindication for laparoscopic operations involving the retroperitoneum. Pre-operative 3D CECT helps to identify the presence of anatomical variations and guides surgical resection.

Robot‐assisted laparoscopic surgery for rectal cancer in a patient with a horseshoe kidney: A case report

“…Abnormalities of renal artery have sometimes been reported to branch off the aorta, iliac artery, or IMA and care should be taken not to damage them during medial dissection to maintain blood flow, and the site of IMA ligation should also be considered occasionally. 1,2 The ureter and gonadal arteriovenous vessels are reported to often travel anterior to the kidney, although cases involving abnormal running of the ureter or duplicate ureters have been reported. Placement of a fluorescent ureteral catheter to prevent intraoperative ureteral injury has been recommended.…”

“…Although the magnifying effect of the scope is promising for dissection and identification of the dissected layer, the use of straight forceps and the restricted approach direction during surgery require caution when manipulating around the IMA root and interfere with the medial approach due to the protrusion of the descending renal parenchyma and isthmus. 1,2 Robot-assisted surgery with the Da Vinci surgical system has a three-dimensional video imaging system and a flexible arm, which may be useful in understanding fine anatomy and protecting organs. [7][8][9] In the present case, the visibility of the hypogastric nerve was excellent, and the nerve traveled anterior to the kidney, confirming preservation of the nerve all the way to the IMA root.…”

“…Its incidence is about 0.25%, and it is often associated with vascular, ureteral, gonadal, and neural anomalies. 1 Recently, there have been some case reports of laparoscopic surgery for sigmoid colon cancer or rectal cancer with a horseshoe kidney, [1][2][3][4][5] but no reports of robot-assisted surgery were found. In this report, a case of robot-assisted, laparoscopic, low anterior resection for rectal cancer in a patient with a horseshoe kidney is described.…”

Literature Review of Anatomical Variations: Clinical Significance, Identification Approach, and Teaching Strategies

“…Kim et al [33] also presented a novel variation identified during routine dissection in which the posterior division of the femoral nerve was penetrated by the ascending branch of the lateral circumflex femoral artery. Preoperative medical scans helped Vigneshwaran and his colleagues [34] to identify double variations of a horseshoe kidney and an accessory renal artery in a challenging case of low rectal cancer planned for laparoscopic resection. In addition, during preoperative diagnosis of a living liver donor, Gündoğdu and Kebapçı [35] observed an accessory right hepatic artery originating from the dorsal pancreatic artery and a middle hepatic artery arising from the pancreaticoduodenal artery.…”

“…In addition, during preoperative diagnosis of a living liver donor, Gündoğdu and Kebapçı [35] observed an accessory right hepatic artery originating from the dorsal pancreatic artery and a middle hepatic artery arising from the pancreaticoduodenal artery. These preoperative observations of anatomical variations guided the surgeons to safe surgical resection of the cancer, and they searched for a new liver donor [34,35].…”