Robotic Transabdominal Control of the Suprahepatic, Infradiaphragmatic Vena Cava to Enable Level 3 Caval Tumor Thrombectomy: Pilot Study in a Perfused-Cadaver Model.

PURPOSE To develop a robotic technique for exclusively transabdominal control of the suprahepatic, infradiaphragmatic inferior vena cava (IVC) to enable level 3 IVC tumor thrombectomy. MATERIALS AND METHODS Robotic technique was developed in three fresh, perfused-model cadavers. Preoperatively, inflow (right jugular vein) and outflow (left femoral vein) cannulae were inserted and connected to a centrifugal pump to establish a 10 mmHg pressure in the IVC for the water-perfused cadaver model. Using a five-port transperitoneal robotic approach, the falciform ligament was detached from the anterior abdominal wall toward its junction with the diaphragm and tautly retracted caudally; this adequately retracted the liver caudally as well. Triangular and coronary ligaments were incised, allowing ready visualization of suprahepatic/infradiaphragmatic IVC and right/left main hepatic veins. Under direct robotic visualization, IVC was circumferentially mobilized, vessel-looped, and controlled. RESULTS All three robotic procedures were successfully completed transabdominally. Average robotic time to control the suprahepatic IVC was 37 minutes; in each case, the suprahepatic IVC was circumferentially controlled with a vessel-loop. There were no intraoperative complications. Length of the mobilized suprahepatic IVC measured between 2 and 3 cm. Right and left suprahepatic veins were clearly visualized in each case. Necropsy revealed no intra-abdominal/intrathoracic visceral or vascular injuries to the suprahepatic IVC, bilateral hepatic veins, or tributaries. CONCLUSIONS We developed a novel robotic technique for transabdominal control of the suprahepatic infradiaphragmatic IVC in a perfused human cadaver model. This approach may extend the application of advanced robotic techniques for the performance of major vena caval, hepatic, and level 3 IVC renal tumor thrombus surgery.

[1]  M. Gallucci,et al.  Robotic Level III Inferior Vena Cava Tumor Thrombectomy: Initial Series. , 2015, The Journal of urology.

[2]  G. Bratslavsky,et al.  V5-06 THE FIRST REPORT OF ROBOTIC ASSISTED RADICAL NEPHRECTOMY WITH RETROHEPATIC VENA CAVAL TUMOR THROMBECTOMY AND EXTENDED RETROPERITONEAL LYMPH NODE DISSECTION , 2014 .

[3]  R. Sotelo,et al.  V7-02 ROBOTIC LEVEL 3 CAVA THROMBECTOMY , 2014 .

[4]  I. Gill,et al.  Robotic inferior vena cava thrombus surgery: novel strategies , 2014, Current opinion in urology.

[5]  I. Gill,et al.  Minimally Invasive Approach to the Supradiaphragmatic Inferior Vena Cava , 2014, Innovations.

[6]  R. Abaza.  Initial series of robotic radical nephrectomy with vena caval tumor thrombectomy. , 2011, European urology.

[7]  J. Kaouk,et al.  Laparoscopic inferior vena cava and right atrial thrombectomy utilizing deep hypothermic circulatory arrest. , 2003, Journal of endourology.

[8]  J. Kaouk,et al.  Laparoscopic radical nephrectomy for cancer with level I renal vein involvement. , 2003, The Journal of urology.

[9]  J. Kaouk,et al.  Laparoscopic radical nephrectomy with level II vena caval thrombectomy: survival porcine study. , 2002, The Journal of urology.

[10]  I. Gill,et al.  Laparoscopic radical nephrectomy for renal cell carcinoma in a patient with level I renal vein tumor thrombus. , 2000, The Journal of urology.

[11]  R. Clayman,et al.  Laparoscopic radical nephrectomy for renal tumor: the Washington University experience. , 1996, The Journal of urology.

[12]  H. Zincke,et al.  Surgical treatment of renal cancer with vena cava extension. , 1987, British journal of urology.