V06-01: Robot Assisted Inferior Vena Cavoscopy
Conventional therapy of inferior vena cava tumor invasion (IVC) retroperitoneal malignancies involves caval resection with or without vascular grafting. Assessment of the extent of tumor invasion relies on preoperative (CT and MRI) and intraoperative (US) imaging. However, these imaging modalities cannot differentiate between bland and tumor thrombi. In this video we are presenting a technique for direct visualization of the IVC lumen to assess for tumor invasion during a robot assisted retroperitoneal lymph node dissection for testicular cancer.
A 29 year old male patient with metastatic non-seminomatous mixed germ cell tumor was found to have a persistent metastatic retroperitoneal lymph node mass following four cycles of BEP chemotherapy. Preoperative imaging demonstrated a 6 cm interaortocaval mass with adjacent filling defect in the IVC. Preoperative imaging could not differentiate between tumor invasion vs bland thrombus.
After induction of general anesthesia, the patient was placed in a modified lithotomy position. Following port placement and robot docking, the small bowel was retracted cephalad and to the left upper quadrant. The retroperitoneal space was developed. Retroperitoneal lymph node dissection was started in a regular manner. The large mass was encountered in the interaortocaval region and was adherent to the IVC wall. It was dissected free from all attachments except the IVC wall. Proximal and distal control was obtained with vessel loops. A small venotomy was made on the IVC anterior wall just distal to the mass. A flexible cystoscope was introduced through one of the assistant ports and into the IVC lumen. Examination of the IVC showed multiple synechiae and vascular webs consistent with organized and recanalized bland thrombus with no evidence of tumor invasion. Given these findings no caval resection was needed. These webs were excised and the remaining part of the wall reconstructed, preserving more than 50% of the IVC circumference. The remaining part of the dissection was completed in the conventional manner. Operative time was 383 min, EBL was 150 ml, and LOS was one day. Postoperatively patient had smooth recovery with no postoperative complication. Postoperative pathology was consistent with a bland thrombus. Follow up imaging showed preserved IVC circumference and no filling defects.
Direct visualization of the IVC lumen is feasible using conventional endoscopic instruments and robotic approach. This helps avoid a large venotomy or graft placement and completion of the retroperitoneal lymph node dissection in a minimally invasive manner.