Category: Laparoscopy: Upper Tract - Malignant
Introduction & Objective :
In this video,we aimed to share our experience with laparoscopic tumor thrombectomy for level 2 tumor thrombus extending into vena cava inferior(VCI) in right kidney tumor.
61-year-old male patient with hematuria was found to have large solid mass infiltrating more than 2/3 of right kidney and extending into VCI with 35x24mm solid component on MRI.Patient was scheduled for right laparoscopic radical nephrectomy and VCI tumor thrombectomy.Patient was placed in 60 degrees lateral decubitus position and pneumoperitoneum was achieved with Veress needle that was inserted right lateral to umbilicus.12-mm port was inserted from the Veress needle site and under direct vision one 12-mm and three 5-mm working ports were placed.Following medialization of the right colon and Kocherization of the duodenum,renal hilum was reached under guidance of right ureter.VCI was dissected off the surrounding tissues.Left renal vein(LRV) was found and released from the surrounding tissues. Renal artery was found and clipped with hem-o-lok clips in the interaortacaval space.Then posterior of the VCI was dissected.Borders of the thrombus on the proximal and distal part of the VCI were dissected and secured with vascular tapes.Kidney was completely dissected off from the surrounding tissues by the aid of Thunderbeat device.In the first instance,distal VCI was clamped with Rummel’s tourniquet(RT).Then endo-bulldog clamp was placed on the LRV and lastly, the proximal VCI was clamped with RT. Nearly 4cm cavatomy was performed with laparoscopic Potts scissors starting from the right RV’s distal insertion point on the VCI.Tumor thrombus was released from the VCI wall completely in continuation with the nephrectomy material.Right modified Gibson incision(MGİ) was performed and 15-mm endo-bag was introduced into abdominal cavity.Specimen was carefully placed into the endobag avoiding contact with the tissues.Defect on the VCI was closed with 5/0 Gore-Tex suture in continuous fashion.After releasing the endo-bulldog clamp on LRV, distal and proximal clamps were released respectively.No bleeding or oozing occurred.The specimen was taken out from the MGİ.Then paracaval lymph node dissection was performed.
Insufflation duration was 120 minutes and estimated blood loss was 100cc.Patient was discharged after his drain was pulled out on postoperative day 2.Pathologic examination revealed clear cell type renal cell carcinoma,Fuhrman Grade 3,pT3b with negative lymph nodes and surgical margins.
Even level II VCI tumor thrombi can be treated laparoscopically without compromising from oncological principles in selected cases by experienced centers.
Ender Ozden– Professor in Urology, Ondokuz Mayis University, School of Medicine, Department of Urology, Atakum, Samsun, Turkey
Murat Gulsen– Atakum, Samsun, Turkey
Suleyman Oner– atakum, Samsun, Turkey
Yakup Bostanci– Atakum, Samsun, Turkey
Yarkın Kamil Yakupoglu– Atakum, Samsun, Turkey
Professor in Urology
Ondokuz Mayis University, School of Medicine, Department of Urology
Atakum, Samsun, Turkey