case_images: PMC9981961_01
case_images: CTU and CTA was performed, and it confirmed SIT (A-E) with a tumor in the left kidney (B-E). It showed that the left renal artery had anatomical variation (E), the arterial phase (B), the venous phase (C), the coronal view (D).
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case_images: PMC9981961_01_fsurg-10-1095591-g001.jpg
case_images: F1
case_images: Computer tomography urography (CTU) and angiography (CTA) showed that the stomach and spleen were located in the right abdominal cavity, while the right hepatic lobe, gallbladder and inferior vena cava were at the left side of his abdomen (Figures 1A-E), the bilateral kidneys were normal in size and shape, but a 24 x 35 mm isodense mass protruded from the outline of the left kidney (Figures 1B-E). On contrast-enhanced computed tomography (CT) scan, the mass was strongly enhanced in the arterial phase (Figure 1C), and the enhancement pattern was attenuated during the venous phase (Figure 1D). Additionally, the left renal artery was supplied by one renal artery and one accessory renal artery (Figure 1E).
case_images: The left RALPN was performed. Adhesions were observed between the entire colon and the anterior abdominal wall, and the liver and the visual field of the surgical area could not be visualized (A,B). After adhesions between the colon and the anterior abdominal wall were removed, the liver and kidney areas on the left were exposed (B-D). The inferior vena cava was located on the left side (E,H), accurate dissection of the left renal hilar vessels (E), three arterial branches were dissected (including one from the abdominal aorta to the lower pole of the kidney, and two from the main renal artery to the middle and lower poles of the kidney) (F). The tumor was isolated and the margin was marked (G). Two branched renal arteries were blocked (H). The tumor was completely removed and the left renal margin was sutured accurately (I).
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case_images: PMC9981961_01_fsurg-10-1095591-g002.jpg
case_images: F2
case_images: A laparoscope was then inserted to observe the abdominal cavity, adhesions were observed between the entire colon and the anterior abdominal wall, particularly between the intestines (Figures 2A,B). When the robotic laparoscopy system was ready, adhesions between the colon and the anterior abdominal wall were removed (Figure 2B-D). The transposed organs, including the liver, spleen, stomach and colon, were then noted (Figure 2C,D). The inferior vena cava was located on the left side (Figure 2E-H). A protruding tumour (Figure 2G) was found in the left kidney, three arterial branches were dissected (including one from the abdominal aorta to the lower pole of the kidney, and two from the main renal artery to the middle and lower poles of the kidney) (Figure 2F). The surgery was uneventful, and the tumour was resected successfully while preserving the tumour capsule (Figure 2I).
case_images: The distribution of ports in this case (A). Specimen: tumour capsule integrity (B).
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case_images: PMC9981961_01_fsurg-10-1095591-g003.jpg
case_images: F3
case_images: Under direct laparoscopy, two 8-mm robotic ports were respectively placed in adhesion-free areas in the intestine 4 cm from the anterior superior iliac spine and under the costal margin (Figure 3A), while a 12-mm assistant port was inserted 5 cm under the umbilicus at the midline (Figure 3A). A 23 x 36 mm specimen was removed from the left kidney and sectioned to confirm tumour capsule integrity (Figure 3B).
case_images: Microscopic appearance (A,B). Pathology revealed pT1aN0M0 Fuhrman Grade I ccRCC (hematoxilyn and eosin staining, x200 (A), x400 (B)).
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case_images: PMC9981961_01_fsurg-10-1095591-g004.jpg
case_images: F4
case_images: Pathology revealed pT1aN0M0 Fuhrman Grade I ccRCC, which did not involve the surgical margins (Figure 4A,B).