Baojun Wang1, Hongzhao Li1, Qingbo Huang1, Kan Liu1, Yang Fan1, Cheng Peng1, Liangyou Gu1, Xintao Li1, Gang Guo1, Rong Liu2, Minggen Hu2, Guodong Zhao2, Hongguang Wang3, Fengyong Liu4, Jiang Xiong5, Xu Zhang6, Xin Ma7. 1. Department of Urology, Chinese PLA General Hospital, Beijing, China. 2. Department of Second Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, China. 3. Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, China. 4. Department of Intervention Therapy, Chinese PLA General Hospital, Beijing, China. 5. Department of Vascular Surgery, Chinese PLA General Hospital, Beijing, China. 6. Department of Urology, Chinese PLA General Hospital, Beijing, China. Electronic address: xzhang@foxmail.com. 7. Department of Urology, Chinese PLA General Hospital, Beijing, China. Electronic address: urologist@foxmail.com.
Abstract
BACKGROUND: Robot-assisted retrohepatic inferior vena cava (IVC) thrombectomy (RA-R-IVCTE) has been reported only for limited series. OBJECTIVE: To describe in detail the techniques for RA-R-IVCTE with regard to the relationship of a proximal thrombus to either the first porta hepatis (FPH) or second porta hepatis (SPH). DESIGN, SETTING, AND PARTICIPANTS: From May 2013 to July 2016, 22 patients with R-IVC tumor thrombi were admitted to our hospital. SURGICAL PROCEDURE: RA-R-IVCTE was performed using the Rummel tourniquet technique. For a proximal thrombus inferior to the FPH, we ligated some short hepatic veins (SHVs; typically 1-3). For a thrombus between the FPH and SPH, we mobilized the right lobe of the liver from the IVC by ligating additional SHVs. For a thrombus near or above the SPH but below the diaphragm, we mobilized both the right and left lobes of the liver to obtain high proximal control of the suprahepatic and infradiaphragmatic IVC, and simultaneously clamped the FPH. MEASUREMENTS: Detailed techniques were described for various scenarios and perioperative outcomes were recorded. RESULTS AND LIMITATIONS: The median operation time was 285min (interquartile range [IQR] 191-390). Intraoperative estimated blood loss was 1350ml (IQR 1000-2075ml). Some 63.6% of patients required an intraoperative blood transfusion and 68% were transferred to the intensive care unit after surgery. Grade IV complications developed in five cases. Vascular injuries (4 cases) were treated with intraoperative endoscopic sutures. An intestinal fistula was found on postoperative day 7 in one case; treatment with gastrointestinal decompression and drainage resolved the condition by 1 mo. CONCLUSIONS: Even though the risks involved are high, RA-R-IVCTE is feasible for selected patients. The FPH/SPH is an important boundary landmark for RA-R-IVCTE. The location of proximal IVC tumor thrombi in relation to the FPH or SPH should determine the technique used. PATIENT SUMMARY: Robot-assisted thrombectomy for retrohepatic inferior vena cava tumor thrombus is feasible in selected patients.
BACKGROUND: Robot-assisted retrohepatic inferior vena cava (IVC) thrombectomy (RA-R-IVCTE) has been reported only for limited series. OBJECTIVE: To describe in detail the techniques for RA-R-IVCTE with regard to the relationship of a proximal thrombus to either the first porta hepatis (FPH) or second porta hepatis (SPH). DESIGN, SETTING, AND PARTICIPANTS: From May 2013 to July 2016, 22 patients with R-IVC tumor thrombi were admitted to our hospital. SURGICAL PROCEDURE: RA-R-IVCTE was performed using the Rummel tourniquet technique. For a proximal thrombus inferior to the FPH, we ligated some short hepatic veins (SHVs; typically 1-3). For a thrombus between the FPH and SPH, we mobilized the right lobe of the liver from the IVC by ligating additional SHVs. For a thrombus near or above the SPH but below the diaphragm, we mobilized both the right and left lobes of the liver to obtain high proximal control of the suprahepatic and infradiaphragmatic IVC, and simultaneously clamped the FPH. MEASUREMENTS: Detailed techniques were described for various scenarios and perioperative outcomes were recorded. RESULTS AND LIMITATIONS: The median operation time was 285min (interquartile range [IQR] 191-390). Intraoperative estimated blood loss was 1350ml (IQR 1000-2075ml). Some 63.6% of patients required an intraoperative blood transfusion and 68% were transferred to the intensive care unit after surgery. Grade IV complications developed in five cases. Vascular injuries (4 cases) were treated with intraoperative endoscopic sutures. An intestinal fistula was found on postoperative day 7 in one case; treatment with gastrointestinal decompression and drainage resolved the condition by 1 mo. CONCLUSIONS: Even though the risks involved are high, RA-R-IVCTE is feasible for selected patients. The FPH/SPH is an important boundary landmark for RA-R-IVCTE. The location of proximal IVC tumor thrombi in relation to the FPH or SPH should determine the technique used. PATIENT SUMMARY: Robot-assisted thrombectomy for retrohepatic inferior vena cava tumor thrombus is feasible in selected patients.
Authors: Christopher Pulford; Kevin Keating; Matthew Rohloff; David Peifer; Richard Eames; Jaschar Shakuri-Rad; Thomas Maatman Journal: Int Braz J Urol Date: 2022 Jan-Feb Impact factor: 1.541