Robotic inferior vena cava (IVC) thrombectomy is a complex and challenging surgical operation. Optimal control of the IVC is crucial to avoid major intraoperative complications such as bleeding and embolism. Two approaches have been described for proximal control of the IVC in robotic surgery: 1. extraluminal approach by cross clamping using Rummel tourniquets or with one or more bulldog clamps or a Satinsky clamp replacing one or more of the tourniquets and 2. endoluminal approach by intracaval balloon occlusion using a Fogarty balloon catheter inserted through a cavotomy. Herein, we describe another endoluminal method using a Reliant® stent graft balloon catheter (SGBC) inserted through endovascular access through the right internal jugular vein (IJV) under fluoroscopy and placed above the tumor thrombus.
The case is a 60-year-old male patient who presented with a 10-cm left renal cell carcinoma (RCC) with a level II thrombus. Left renal artery embolization with gel foam was performed the night before the procedure. Two right renal veins were found, and vessel loops and Rummel tourniquets were applied. Then, IVC mobilization above and below the IVC thrombus was obtained. The IVC was vessel looped below the thrombus, and Rummel tourniquets were applied between the 2 right renal veins and above the thrombus. Next, the Reliant® SGBC was inserted through the IJV under fluoroscopy and intraoperative ultrasound guidance and placed above the thrombus in the suprarenal IVC. Then, vessel loops on the first right renal vein and infra-thrombus IVC were cinched, followed by balloon inflation above the thrombus. A vascular stapler was applied across the left renal vein at the junction with the IVC. Next, a cavotomy was made and the thrombus and stapled IVC wall were removed with a retrieval bag. The IVC was repaired using 4-0 Gortex® sutures followed by removal of all of the vessel loops.
The procedure was successfully performed in a minimally invasive fashion. The estimated blood loss was 250 cc, the operative time was 6 hours and 43 minutes for both IVC thrombectomy and radical nephrectomy. The IVC clamp time was 41 minutes. The postoperative period was uneventful, and the patient was discharged home on day three post-operatively. The histopathology report showed clear cell RCC, pT3c N0 M1, with negative margins and metastasis to the adrenal gland.
The application of advanced techniques and instrumentation has allowed renal tumors involving the IVC to be managed in a purely minimally invasive fashion. Our technique has demonstrated the feasibility of obtaining proximal control of the IVC using a Reliant® SGBC.