Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery:
Hui, Dawn S. MD*; Gill, Inderbir S. MD, MCh†; Cunningham, Mark J. MD*
From the *CardioVascular Thoracic Institute, Department of Cardiothoracic Surgery, and †USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA USA.
Accepted for publication December 29, 2013.
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Disclosures: Inderbir S. Gill, MD, MCh, is a consultant to EDAP TMS, Lyon, France, and holds stock options in Hansen Medical, Inc., Mountain View, CA USA. Dawn S. Hui, MD, and Mark J. Cunningham, MD, declare no conflicts of interest.
Address correspondence and reprint requests to Mark J. Cunningham, MD, Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, 1520 San Pablo St, HCCII, Suite 4300, Los Angeles, CA 90033 USA. E-mail: Mark.Cunningham@med.usc.edu.
Minimally invasive techniques for cardiac operations have evolved in safety and popularity. To our knowledge, a thoracoscopic technique for control of the inferior vena cava (IVC) has not been previously described. We report a case of a right renal cell cancer with tumor extension into the IVC. Total thoracoscopic isolation and occlusion of the IVC were performed. Intraoperative real-time transesophageal echocardiography confirmed complete cessation of caval flow upon cinching the Rummel tourniquet. As extensive intra-abdominal operations are more often being attempted laparoscopically or robotically, video-assisted thoracoscopic IVC occlusion for proximal control for tumors extending into the cava can be achieved to offer a minimally invasive thoracic approach.
Minimally invasive techniques for cardiac operations have evolved in safety and popularity. To our knowledge, a thoracoscopic technique for control of the inferior vena cava (IVC) has not been previously described. We report a case of right renal cell cancer with level III tumor extension into the IVC. Total thoracoscopic isolation and occlusion of the IVC are described.
A 73-year-old woman with a history of hypertension presented with hematuria and right flank pain. Imaging demonstrated a right renal cell tumor extending into the IVC beyond the level of the hepatic veins (Fig. 1).
The planned approach was an all-port access operation, comprising video-assisted thoracoscopic isolation of the supradiaphragmatic IVC, laparoscopic control of the porta hepatis with the Pringle maneuver, and a robotic right radical nephrectomy and resection of vena cava tumor thrombus. With the patient positioned supine, a double-lumen endotracheal tube intubation was placed for selective ventilation. Intraoperative transesophageal echocardiography (TEE) demonstrated normal ventricular function and no thrombus in the supradiaphragmatic IVC. A camera port was placed at the right fourth intercostal space, and a 10-mm 30-degree camera was used throughout the case. Working ports were placed at the third intercostal space at the midclavicular line and at the sixth intercostal space at the midaxillary line. An additional port was placed at the 10th intercostal space for a diaphragmatic retracting instrument (Fig. 2).
Exposure was optimized with low-pressure (<10 mm Hg) CO2 insufflation and intermittent apnea. Using hook electrocautery, the pericardium was incised longitudinally 2 cm anterior to the phrenic nerve, with the superior extent being the level of the right atrial appendage. The inferior extent was the central tendon. Inferiorly, exposure was improved by placing a laparoscopic finger retractor to depress the diaphragm. The IVC was bluntly dissected circumferentially from the pericardium. An articulating lighted curved dissector (AtriCure, Inc, Cincinnati, OH USA) was passed into the oblique sinus posterior to the IVC, and the tip was rotated anteriorly. A transfer guide had been preattached to the dissector tip. This was exchanged for a red rubber catheter to isolate the IVC; this was then exchanged for an umbilical tape. A Rummel tourniquet passed through the right side of the chest was applied. Intraoperative real-time TEE confirmed complete cessation of caval flow upon cinching the Rummel tourniquet (Fig. 3) (see Video, Supplemental Digital Content, Operative technique and TEE, available at http://links.lww.com/INNOV/A42).
Thoracoscopic IVC control was accomplished and successfully used to proximally occlude the IVC with a Rummel tourniquet. Operative time for the thoracoscopic procedure was 1 hour with minimal (10–20 mL) blood loss. Right radical nephrectomy with IVC thrombectomy and excision of IVC was attempted robotically; however, the densely adherent caval thrombus necessitated open conversion for complete thrombus extraction and caval closure. Histology showed a 4.8-cm T3 grade 3 clear cell carcinoma with negative margins, adherent to the IVC wall without invasion.
Total thoracoscopic isolation of the IVC is technically feasible. To provide exposure, adjunctive measures such as intrathoracic CO2 insufflation and intermittent apnea are used. These measures mandate constant communication between the surgical and anesthesia teams, with careful attention to the patient’s hemodynamic and volume status. The volume of the right atrium affects the ability to adequately visualize the IVC, and manipulation of the atrium can trigger atrial arrhythmias.
Surgical intervention remains the only chance for cure of renal cell carcinoma with tumor thrombus involvement of the IVC. The Mayo classification of macroscopic venous invasion (Table 1) is relevant to planning the surgical management of proximal IVC control. Level IV tumors have generally required cardiopulmonary bypass with or without deep hypothermic circulatory arrest, but advances in surgical techniques have allowed avoidance of sternotomy in level III tumors.2,3 These techniques have even been extended to level IV tumors4 to avoid sternotomy and cardiopulmonary bypass. However, each of these methods relies on an open abdominal incision and violation of the diaphragm to reach the intrathoracic IVC and to manipulate the venous tumor thrombus for complete resection.
Recently, minimally invasive techniques of radical nephrectomy for renal cell carcinoma have been shown to be safe from both surgical and oncologic standpoints,5 even in large tumors.6 Robotic approaches to renal cell carcinoma with limited IVC thrombus have been described.7,8 The technique described here allows extension of the IVC control in a minimally invasive fashion, which hitherto has not been possible. In the future, given adequate expertise, this thoracoscopic approach could be used in conjunction with transabdominal laparoscopic/robotic techniques for management of advanced abdominal cancers with level III IVC thrombus involvement.
As extensive intra-abdominal operations are more often being attempted laparoscopically or robotically, video-assisted thoracoscopic IVC occlusion for proximal control of tumors extending into the cava can be achieved to offer complete minimally invasive access in selected patients. This approach requires careful preoperative planning, coordination between the surgical and anesthesia teams, and careful attention to intraoperative monitoring.
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6. Meraney AM, Gill IS, Desai M, et al. Laparoscopic inferior vena cava and right atrial thrombectomy utilizing deep hypothermic circulatory arrest. J Endourol. 2003; 17: 275–282.
7. Desai MM, Gill IS, Ramani AP, Matin SF, Kaouk JH, Campero JM. Laparoscopic radical nephrectomy for cancer with level I renal vein involvement. J Urol. 2003; 169: 487–491.
8. Abaza R. Initial series of robotic radical nephrectomy with vena caval tumor thrombectomy. Eur Urol. 2011; 59: 652–656.
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