V5-09: Abdominal access to retro hepatic and supra hepatic IVC thrombus in renal cell carcinoma
VideoIntroductions and Objectives
Surgery for retro hepatic and suprahepatic thrombus in renal cell carcinoma is associated with high morbidity and mortality. Abdominal access to the thrombus with liver mobilisation avoids cardiopulmonary bye pass and its associated complications .This video describes the technique used.
Through a Chevron incision with a superior midline extension,the colon is mobilised to expose the renal tumor. Liver mobilisation is started by dividing the coronary ligaments and the caudate lobe is separated dividing the vessels to the inferior vena cava. The porta hepatis is secured with a tourniquet through an opening in the lesser omentum . Rotating the right lobe to the left, the hepatic veins are exposed, dissected and looped. The diaphragmatic hiatus is dissected to encircle the superior aspect of the cava. Once the renal artery is ligated and divided, the contralateral renal artery and vein are looped. Control of the cava is obtained above the level of the thrombus and below the renal veins. A Satinsky is clamp is placed above the level of the thrombus after tightening all the loops and the IVC is opened to remove the thrombus. If the thrombus is above the level of the hepatic veins an attempt is made to milk it down to below the hepatic veins using the Pringles manoeuvre. If not, as described by Ciancio et al, the cava is clamped to remove the thrombus upto the level below the hepatic veins.The part of the cava above the hepatic vein is closed, the clamp repositioned below the hepatic veins and the hepatic circulation restored. With a further extension of the cavotomy the rest of the thrombus is removed.
Of 37 cases of caval thrombus in renal cell carcinoma over a 12 year period, 11 cases with retro hepatic and supra hepatic caval thrombus were treated in this manner. In two, the cavotomy above the hepatic veins had to be sutured and the clamp repositioned. In two others, the thrombus could be milked below the hepatic vein with Pringles manoeuvre. In four,part of the caval wall had to be resected due to adherent thrombus. The median follow up was 17 months (range 1-54) months.There was no perioperative mortality. One had prolonged ileus and 2 developed wound infection.
Abdominal approach with liver mobilisation gives excellent access to the inferior vena cava for removal of retrohepatic and suprahepatic thrombus in renal cell carcinoma.The morbidity is minimal and can avoid cardiopulmonary bye pass.