The patient was placed in the supine position under general anesthesia. The general surgery team performed a standard robot-assisted distal gastrectomy. She received preoperative endoscopic clipping to identify the lesion during surgery. A 12-mm camera port was inserted just below the umbilicus via direct vision. After CO₂ gas insufflation, three additional 8-mm ports for robotic arms were placed under camera visualization. The ports for arm numbers 1 and 3 were placed in symmetrical fashion, 1 cm below the subcostal margin along both midclavicular lines. The port for arm number 2 was placed 2 cm superior to the umbilicus, between the port for arm number 1 and the camera port. A 12-mm assistant port was inserted 1 cm superior to the umbilicus, between the port for arm number 3 and the camera port (Fig. 2). For liver retraction, a puncture method with a 2-0 Prolene® (Ethicon, Norderstedt, Germany) straight needle was used. After docking the robot, distal gastrectomy was performed in the usual fashion. The operative procedure for distal gastrectomy has been previously described (Fig. 3).2,4,5,6 Complete D2 lymph node dissection around the stomach was performed.

After undocking the robot, a 5-cm vertical midline incision was made, the stomach was removed, and the clips were identified by palpation. After gastric resection, the proximal and distal margins were sent for frozen section examination to confirm negative resection margins. Extracorporeal antecolic gastrojejunostomy was performed using a circular stapler. The incision for mini laparotomy and the port sites in the left abdomen were closed. Other port sites and the abdomen were covered with sterile adhesive drape in case the port sites were reused during partial nephrectomy.

The patient was repositioned to the left lateral decubitus position. The 12-mm umbilical incision was re-used for the assistant port. Then, the 12-mm camera port was inserted 5 cm above the umbilicus to the midline, at the level of the renal hilum. The port for robotic arm number 1 was placed in the 3 finger medial point of the anterior superior iliac spine. The port for arm number 2 was placed in the anterior axillary line at the level of the umbilicus. The port for arm number 3 was placed at the junction of the costal margin and the lateral edge of the rectus muscle. A 5-mm trocar was inserted just below the xiphoid process for liver retraction (Fig. 2). Intraoperative ultrasonography was used to identify the tumor extent. The operative procedure for a partial nephrectomy was performed as previously described (Fig. 3).3,7 The specimen was retrieved using a laparoscopic retrieval bag through the assistant port. Warm ischemia time was 18 minutes. Intraoperative frozen biopsy showed negative resection margins.

The total operation time was 670 minutes (distal gastrectomy, 400 minutes; partial nephrectomy, 270 minutes). The total console time was 370 minutes (distal gastrectomy, 260 minutes; partial nephrectomy, 110 minutes). Estimated blood loss was 300 ml (distal gastrectomy, 100 ml; partial nephrectomy, 200 ml). On postoperative day 5, the patient had a high spiking fever of 39.5℃. A gastrografin upper gastrointestinal series showed no evidence of anastomosis leakage. Abdominal computed tomography showed a complicated fluid collection around the partial nephrectomy site. Intravenous antibiotics were administered and follow-up abdominal computed tomography was performed on postoperative day 13. Computed tomography showed decreased fluid collection around the partial nephrectomy site. The patient was discharged on postoperative day 17. Final pathological examination from the distal gastrectomy showed a 1.6×0.7 cm sized signet ring cell carcinoma, localized within the lamina propria. No metastasis was observed in any of 44 retrieved lymph nodes. The final stage was pT1aN0, stage 1A according to the American Joint Committee on Cancer 7th Edition. Final pathological examination of the partial nephrectomy showed a 3×3 cm sized renal cell carcinoma clear cell type, Fuhrman's nuclear grade II/IV with negative resection margins (Fig. 4). The pathologic stage was T1a. The patient had no evidence of late complications or recurrence at 6 month.