Surgical Tips for Inferior Vena Cava Thrombectomy

Robot‐assisted radical nephrectomy and inferior vena cava tumor thrombectomy: Initial experience in Japan

“…In this case, no significant complication occurred, resulting in the achievement of satisfactory perioperative outcomes. In addition, contrary to previous studies showing a longer operative time, [2][3][4][5][6][7] the robotic procedure in this case could be completed within 3 h. These favorable outcomes could be explained, at least in part, by the extensive experience of the operator, who has been involved in open surgery for >100 cases with RCC and an IVC thrombus as well as robotic renal surgery for >300 cases, including partial nephrectomy, RN, and pyeloplasty. Accordingly, if performed by a wellexperienced surgeon, purely robotic surgery could be a reasonable approach for the treatment of RCC with an IVC thrombus corresponding to level I.…”

“…Since the first description, 3 robotic surgery for RCC with a tumor thrombus in the IVC has been increasingly utilized as a minimally invasive alternative to a traditional open surgery, and outcomes of robotic surgery were shown to be feasible, leading to significantly small blood loss and a short hospital stay compared with open approach. [2][3][4][5][6][7] More recently, therefore, a robotic approach has been expanded to RCC with a high-level IVC tumor thrombus by a few teams with sufficient experience of robotic surgery. 9,10 In Japan, RA-RT/IVCTT has not been performed, because RARN has yet to be approved; however, we have conducted RARN after the approval by the research ethics committee.…”

“…First, in this case, IVC and the left renal vein were clamped by both the twice-wrapped vessel loops and bulldogs in careful preparation for massive bleeding. However, only one item, mainly either the Rummel tourniquet or a modified technique, like that in this case, was reported to be used in previous studies [2][3][4][5][6][7] ; therefore, it should be considered to clamp them with the twice-wrapped vessel loops alone to simplify the procedure. Second, when applying the robotic approach in the next case, it will be necessary to discuss whether omitted procedures in this case, such as irrigation of the caval lumen and covering of the removed thrombus with a specimen bag, should be introduced.…”

“…In fact, since the initial report by Abaza et al . in 2011, 3 several studies have reported promising findings for RA‐RN/IVCTT 2–7 . However, this type of robotic surgery is currently performed solely by well‐experienced surgeons in limited high‐volume centers, and RARN has yet to be approved by the health insurance system; thus, RA‐RN/IVCTT has not yet been performed in Japan.…”

Re: Palacios AR, Schmeusser BN, Midenberg E, et al. Resection of retroperitoneal tumors with inferior vena cava involvement without caval reconstruction. J Surg Oncol. 2022. doi:10.1002/jso.27052.

“…We recommend test-driving the ligation (synching Rummel tourniquet) to make sure that hemodynamic status as well as the other kidney will tolerate it; this helps whether reconstruction is needed. 3,4 However, preoperative imaging assessment may also help to predict the need for possible cavectomy. Radiologic features, including degree of IVC occlusion/involvement as well as presence and level of tumor thrombus, patent dilated lumbar veins, and bland distal thrombus have shown to be helpful in surgical planning and hence proper preoperative patient counseling.…”