V3-02: Transperitoneal Robot Assisted Inferior Vena Cava Filter Extraction: You Already Know How to Do This!
In this video we present a technique for robotic removal of an inferior vena cava filter (IVCF) not amenable to endovascular retrieval. Our technique mirrors our established technique for robotic removal of a level I or level II caval thrombus associated with renal cell carcinoma. The index patient is a healthy 31-year old male experiencing epigastric discomfort attributed to a permanent caval filter placed 10 years prior, with radiographic evidence of IVC extrusion.
The patient is positioned in the right-side-up modified flank position. The colon is mobilized and athermal Kocherization of the duodenum is performed with awareness that any extruding struts of the IVCF may perforate adjacent organs. The filter is easily visualized within the exposed cava. After circumferential dissection of the cava above and below the IVCF, occlusion of the IVC is accomplished by placing modified Rummel tourniquets in the form of vessel loops doubly wrapped around the IVC and the bilateral renal veins. To avoid significant blood loss, it is crucial to ligate, bipolar, or staple all lumbar veins. Intravascular heparin is given before tightening the tourniquets. Control of the renal arteries is not necessary. Cavotomy is performed once all inflow is controlled so that a bloodless field is maintained during IVCF extraction. Struts of the filter that have eroded through the vena cava may be broken and removed prior to opening the cava, otherwise the struts can be pulled into the lumen of the vena cava once open, with minimal risk of caval tearing. Caval reconstruction is accomplished with a running 4-0 permanent monofilament suture. Heparinized saline is flushed through the cavotomy prior to closure and before releasing tourniquets to reestablish blood flow.
Operative time was 189 minutes. IVC occlusion time was 25 minutes. Estimated blood loss was 800 ml in this case due to an unrecognized lumbar vein. The patient was discharged to home on postoperative day two. There were no intraoperative or postoperative complications. The patient was continued on 81 mg aspirin at discharge and prophylactic enoxaparin for three weeks. Pain symptoms had improved at 3 month follow up.
This video demonstrates a stepwise technique for transperitoneal robot assisted IVC filter extraction. Urologists with adequate robotic experience in robotic nephrectomy with level I-II IVC tumor thrombus should feel comfortable approaching robotic IVC filter retrieval. It is important to have multidisciplinary support, adequate preoperative imaging, and be familiar with the IVC filter design.