V9-06: Technical Innovations to Robotic Level II and III Thrombectomy: Step by Step

Video

INTRODUCTION

In this video, we demonstrate technical innovations to facilitate robotic Level II and III IVC thrombectomy.

METHODS

Following IVC dissection and ligation of the right renal artery, rommel tourniquets (RT) are placed in the infrarenal IVC (IIVC), left renal vein (LRV), and suprarenal IVC (SIVC). The IIVC and LRV RTs are cinched down. A cavotomy over a purse-string suture is performed just distal to the right renal vein, cephalad to the IIVC RT. A 9Fr Fogarty catheter over a soft-tip glide-wire is advanced into the IVC to an infra-hepatic location, proximal to the thrombus. The catheter balloon is inflated to occlude the IVC and retracted. The right renal vein is stapled. Cavotomy is performed and the thrombus is delivered into an Endocatch bag. The SIVC RT is now cinched down at the level of the right adrenal vein without liver mobilization. The right renal vein ostium and the staple-line are resected. Cavoscopy is performed to ensure no IVC wall invasion by the thrombus. Following IVC reconstruction and release of all RTs, Doppler and ICG confirm IVC flow. Resection of IVC and repair with bovine pericardium is performed if there was any IVC invasion requiring excision of cava.

RESULTS

We successfully performed robotic IVC balloon thrombectomy and bovine path in 3 and 1 patient, respectively. The table provides peri-operative findings. All margins were negative and to date no patient has developed metastasis.

CONCLUSION

The use of a Fogarty balloon for proximal IVC occlusion during robotic IVC thrombectomy for level II and III thrombi is feasible and safe; it facilitates proximal IVC control without the need for short-hepatic vein control, retro-hepatic dissection or liver mobilization. Robotic implantation of a bovine pericardial patch following IVC wall resection is feasible and safe.

Funding: none