Adapting liver transplant techniques for IVC transection and/or thrombectomy for renal cell carcinoma with level 3 vena cava thrombus

Sujoy Pal 1 , Amlesh Seth 2 , Peush Sahni 1 , Tushar Kanti chattopadhyay 1 , Vaibhav Saxena 2 , Ashish Kumar Saini 2 1-Department of GI surgery and Liver Transplantation and 2- Department of Urology All India Institute of Medical Sciences, New Delhi-110029. For sections: Liver/Transplantation/Miscellaneous ABSTRACT Introduction Renal cell carcinoma (RCC) with tumor thrombus in the retrohepatic inferior vena cava (rIVC) is a challenging surgical problem. Preventing massive hemorrhage and tumor thromboembolism often requires complex surgical maneuvers. Procedure Four patients underwent radical resection of right RCC with rIVC (level 3) tumor thrombus using techniques often employed in orthotopic liver transplantation This video illustrates the technical steps. A Mercedes-Benz incision enabled placement of a Rochard retractor. Early ligation of the right renal artery and looping of the left renal vein (LRV) was done. The liver was mobilized to expose the suprahepatic IVC (shIVC).  After volume loading and trial clamping the infrarenal IVC (irIVC), porta and shIVC were sequentially clamped thereby causing total hepatic vascular exclusion (THVE). The liver was mobilized off the rIVC in a 'piggy-back' manner after ligating the short hepatic veins until the upper end of the thrombus was reached. The rIVC was then cross-clamped just above the thrombus. The shIVC and porta clamps were released to restore liver blood flow. Repositioning the proximal clamp and Pringle release avoided using veno-venous bypass. The LRV (and irIVC) was clamped and the thrombus extracted through a infrahepatic cavotomy. irIVC excision was required in one case with an infiltrating tumor thrombus and associated 'bland' thrombus in the irIVC. The upper and lower IVC stumps were closed after ensuring LRV drainage in to the upper rIVC. Outcome The THVE and operative time were 20-24 and 280-300 minutes respectively. Blood loss was 1100-2000 ml. All patients had complete tumor resection, smooth postoperative recovery and no liver dysfunction. None suffered intraoperative thromboembolism. One patient who required IVC excision developed bilateral lower limb edema which resolved gradually. Conclusions The 'liver transplant' approach provides excellent exposure and control of the IVC in RCC cases with level 3 tumor thrombus and helps avoid  intraoperative mishaps and cardiopulmonary bypass.