Single-Position Laparoscopic Radical Nephrectomy with Level IIIa Inferior Vena Cava Thrombectomy

Abstract

Introduction:

The first porta hepatis (FPH) is a crucial anatomical landmark during inferior vena cava thrombectomy (IVC-TE). For a thrombus between the FPH and the second porta hepatis (SPH), liver mobilization is usually required to expose the retrohepatic IVC. ¹ Recently, Wang et al. reported a robot-assisted single-docking approach for the management of level IIIa IVC tumor thrombus. ² However, there are no reports on single-position laparoscopic thrombectomy (TE) for level III thrombus. Herein, we present a laparoscopic level IIIa IVC TE without liver mobilization or patient repositioning.

Materials and Methods:

A 72-year-old man presented with an episode of abdominal pain. Preoperative contrast-enhanced CT and CT venography (CTV) showed right RCC with an IVC thrombus extending to the level of the caudate lobe (above the SPH). No lymph node or distant metastasis was observed. Based on the clinical findings, the decision of right radical nephrectomy and TE was taken. The operation was performed in 70° left lateral decubitus position under general anesthesia. Five laparoscopic ports were placed in the right lumbar and epigastric areas. The key steps include ligation of the right renal artery, IVC, and left renal vein mobilization, lumbar veins transection, short hepatic veins control, IVC and left renal vein occlusion, and thrombus retrieval and IVC anastomosis.

Results:

The total operative time was 150 mins, with an estimated blood loss of 200 mL. The patient remained hemodynamically stable throughout the procedure. Postoperative recovery was uneventful, and the patient was discharged on postoperative day 3. Final pathology revealed stage pT3b clear cell renal cell carcinoma with negative surgical margins. The patient subsequently received six cycles of adjuvant pembrolizumab monotherapy. At 6 months postoperatively, contrast-enhanced CT demonstrated no evidence of tumor recurrence or residual IVC thrombus. At 12-months follow-up, the patient remained clinically well without signs of recurrence.

Conclusions:

Despite the technical challenges, single-position laparoscopic TE is feasible for selected patients with level III thrombus. During the dissection of the retrohepatic IVC at the level of caudate lobe, meticulous ligation of each short hepatic vein is essential. Precise presurgical planning, early imaging interpretation, and contingency planning are necessary for the best outcome. Initial dissection of the inter-aortocaval region is recommended to facilitate early ligation of the right renal artery. For patients with level IIIa thrombus, the infrarenal IVC, left renal vein, and retrohepatic IVC were clamped, and subsequent surgical steps were similar to those described above. ²

The authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure.

There are no conflicts of interest.

Runtime of video: 06 mins 24 secs.