V07-04: Robotic Assisted Level IV Inferior Vena Cava Tumor Thrombectomy
To report the initial case of robotic-assisted level IV inferior vena cava (IVC) tumor thrombectomy.
A 74 year old male presented with an 8 cm right renal tumor and a level IV IVC tumor thrombus, 16 cm in length which was extending 5.2 cm into the right atrium. Metastatic evaluation was negative. Using a 7-port trans-abdominal approach, the porta-hepatis, infra-renal and intra-/retro-hepatic IVC and right kidney were secured. Through a 6 cm, minimally-invasive thoracotomy incision, aortic cross-clamping, cardio-pulmonary bypass with cardiac arrest were performed. Using a simultaneous antegrade-retrograde approach, the thrombus was extracted after opening the right atrium (trans-thoracic) and infra-hepatic IVC (trans-abdominal). Confirmation of total thrombus clearance was achieved by passing a 3 cm diameter Fogarty balloon and endo-luminal inferior vena-cavoscopy.
Total operative time was 9.7 hours, including cardio-pulmonary bypass time of 121 minutes, aortic cross-clamp time of 53 minutes and porta hepatis cross-clamp time of 31 minutes. Nadir core temperature was 32.3 degrees Celsius. Blood loss for the robotic intra-abdominal surgery was 300 cc. A total of 6 units of blood were transfused on the bypass pump; no blood transfusions were required post-operatively. Hospital stay was 6 days, including 4 days observation in intensive care unit. Pathology revealed pT3cN0 grade 4 clear cell renal cell carcinoma invading the peri-renal and central sinus fat, with negative surgical margins. There were no intra-operative or post-operative complications.
The initial report of a robotic-assisted level IV inferior vena cava tumor thrombectomy, with the thrombus extending 5.2 cm into the heart, is presented. This report further extends the field of robotic surgery.