VM67 - Laparoscopic High Anterior Resection in a Patient with a Left Pelvic Kidney: A Video Vignette

Purpose/Background: Anatomic variation often necessitates modification of surgical techniques and can lead to higher rates of intraoperative complications if not identified. A pelvic kidney occurs when it fails to rise from the pelvic position in its metanephros stage during embryogenesis. The prevalence of pelvic kidney is estimated to be 1 per 1000-2000 live births. Patients with pelvic kidneys are usually asymptomatic, and diagnosis is often incidental. A pelvic kidney poses a unique challenge in colorectal surgery as its presence in an inherently narrow space of the pelvic cavity makes access even more limited. Additionally, the vascular anatomy of a pelvic kidney is also variable, and this can also contribute to a difficult dissection if not identified early.
To date there are only 7 case reports in literature on anterior resection and pelvic kidney, of which only one was reported to be done laparoscopically. There are also no video publications on this topic.

Methods/Interventions: This is a video vignette of a laparoscopic high anterior resection for distal sigmoid cancer in a 67-year-old patient with incidentally diagnosed pelvic kidney on preoperative imaging. Her right kidney is in-situ.
The surgery was performed with one surgeon and one assistant, with a 12mm camera port, one 12mm and two 5mm working ports. Surgical video was recorded and edited by the operating surgeons.

Results/Outcomes: The surgery was completed in 135 minutes with minimal blood loss. The patient recovered well after surgery with no complications and was discharged after 3 days.
Difficulty in dissection is highlighted in this video vignette. Firstly, there was limitation of space in the pelvis for dissection due to presence of the left kidney at the pelvic inlet. Second, the sigmoid colon and rectum are displaced to the right. Third, there are congenital adhesions tethering the sigmoid colon to the terminal ileum and cecum, as well as the small bowel mesentery. And lastly, the left renal vein lies in close proximity to the inferior mesenteric artery making dissection challenging.

Conclusion/Discussion: The presence of a pelvic kidney poses a unique challenge in colorectal resections. This is contributed in part by unfamiliar variant anatomy, and limitation of working space. Safe laparoscopic surgery is possible, but the surgeon must be mindful of vascular anomalies and correlations during dissection.
This adds to the literature as the first video publication on this topic.