V7-02: Robotic Level 3 Cava Thrombectomy

Video

Introductions and Objectives
Inferior Vena Cava (IVC) thrombectomy is a major and challenging procedure. In order to safely perform this procedure, the vena cava should be controlled according to the tumor extension. For level I thrombus the renal vein can be stapled. Level 2 thrombus require further dissection and cavotomy, but usually with infrahepatic cava control. However for level 3 caval thrombus complete control of the inferior vena cava is required. When performed open, Level III cava thrombecthomy usualy requires long highly morbid thorachoabdominal incision. Herein we describe a totally minimally invasive control of the vena cava to allow robot-assisted level III cava thrombectomy.

Methods
The first case is a 73-year old female who presented with a right renal cell carcinoma (RCC) with level III IVC thrombus extending up to the diaphragm. Thoracoscpic IVC control was performed using 3 ports. The pericardium was opened anterior to the phrenic nerve and the inferior vena cava dissected from the pericardium. Using a lighted curved dissector, circumferential control was obtained with a Rummel tourniquet. The a laparoscopic Pringle maneuver was performed laparoscopically using 3 ports technique. The retroperitoneum is incised anterior to the IVC and lateral to the hepatoduaodenal ligament. The vena porta is identified. Then an articulated arm is passed posterior to the hepatic hilum and a window on the lesser omentum is created. The hepatoduodenal ligament is vessel looped and Rummel tourniquet is applied. The second case is a 59 year-old male patient with a complex right renal mass and level III retrohepatic IVC thrombus. In this case we show the steps of robotic mobilization and control of the IVC, as well as the technique for opening the vena cava and extracting the tumor thrombus.

Results
The procedures were successfully performed in a minimally invasive fashion. The mean estimated blood loss was: 200 cc. The mean operative time was: 271 min. The second patient developed a subphrenic abscess that required percutaneous drainage.

Conclusions
The application of advanced techniques and instrumentation has allowed renal tumors involving the IVC to be managed in purely minimally invasive fashion. Our technique has demonstrated the feasibility of performing an IVC control for tumors extending into the IVC at different levels.

Funding: None