INTRAHEPATIC TUMOR THROMBECTOMY THROUGH AN ABDOMINAL DIAPHRAGMATIC APPROACH

Abstract

Radical excision of renal cancer with propagation into the intrahepatic and intrapericardial inferior vena cava is an accepted surgical procedure.1.2 In a case of renal cancer with inferior vena caval suprahepatic involvement we verified the possibility of approaching the intrapericardial inferior vena cava through a limited diaphragmatic incision. CASE REPORT In a 75-year-old woman ultrasound and computerized tomography revealed a large solid mass in the left kidney and a vena caval thrombus extending above the suprahepatic veins. Magnetic resonance imaging and venacavography confirmed the diagnosis. The tumor was exposed through a Accepted for publication May 23, 1997. transverse abdominal approach combined with an epigastric vertical incision. The affected kidney was completely freed by ligation and section of the artery, ureter and vascular attachments. It remained attached only to the inferior vena cava and was transposed medially to the left mesocolon. The infrahepatic inferior vena cava was widely exposed by dividing the venous branches to the caudate and left lobes of the liver, and ligating the lumbar vessels. The diaphragm was exposed and incised in the midline at the level of its anterior insertion to the central tendon (fig. 1). The pericardial cavity was immediately entered. The upper extremity of the thrombus, placed at the diaphragm level, was evaluated by intraoperative ultrasound and its extension was confirmed by careful palpation under direct vision. A finger was then passed around the intrapericardial inferior vena cava above the thrombus and an umbilical tape was positioned. Other tapes were positioned around the hepatic hilum, infrarenal inferior vena cava, right renal vein and artery contralateral to the tumor. All tapes were clamped