Complete Resection of the Inferior Vena Cava Using a Robot

Abstract

Isolated intrainferior vena cava (IVC) recurrence of renal cell carcinoma (RCC) is a rare presentation. In this investigator-initiated intervention, we present our novel experience, with first of kind—a robotic suprarenal cavectomy without reconstruction for an isolated RCC recurrence, occurring 3 years postright radical nephrectomy. The patient's procedure was undertaken with a Da Vinci Xi Surgical System®. As step 1, the patient was positioned right lateral side up and routine right nephrectomy port placement was undertaken, followed by side docking. As step 2, the right colon and duodenum were medialized. During step 3, the IVC was identified and en bloc retroperitoneal dissection was performed to fully expose all aspects of the IVC. A significant pericaval fibrotic rind was excised to allow exposure of the true IVC surface. Step 4 involved identification of the left renal vein, with preservation. For step 5, the suprarenal IVC was dissected circumferentially with lumbar veins clipped as necessary. The position and superior margin of the tumor thrombus were constantly confirmed with both transesophageal and robotic intraoperative sonography. Step 6 consisted of further intrahepatic caval dissection, performed to completely expose the suprarenal IVC. For step 7, a rummel-style tourniquet was placed below the level of the thrombus, and the superior margin of the IVC was secured using a Vicryl tie. Step 8 involved caval dissection, with adequate margin of IVC taken proximal to the superior border of the tumor (~2 cm). Once the mass was isolated, step 9 utilized a robotic 60 mm vascular stapler to divide the intrahepatic IVC above the mass and similarly below the mass. This wedge of IVC was collected with thrombus in situ and sent for histopathology. Hemostasis was achieved and port sites were closed in the usual manner. Tumor was confirmed as clear cell RCC (ISUP nucleolar grade 2), in keeping with the man's prior diagnosis. The tumor mass was clear of margins, and a lymph node isolated as part of the specimen demonstrated no evidence of malignancy. Patient progress since discharge has been unremarkable, with no evidence of lower limb edema, clinical or radiologic recurrence of malignancy 3 months since operation. A robot-assisted caval resection for isolated renal carcinoma recurrence within the IVC is a minimally invasive option that can facilitate complete resection with negative surgical margins and minimization of morbidity. Patient Consent Statement: Informed consent was obtained from the patient for publication of this case and accompanying images and video. The authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. No competing financial interests exist. Runtime of video: 5 mins 59 mins