A Step-Step Approach to Robotic Assisted Level 2 IVC Thrombus

This video was entered by Dr. Santoshi Nagaonkar in the 2022 KS International Robotic Surgery Innovation Awards, sponsored by the Vattikuti Foundation. It was featured in the Vattikuti Symposium ‘Humans at the Cutting Edge of Robotic Surgery,’ held in Miami, Florida November 19, 2022.

Here is the Abstract:

A Step-Step Approach to Robotic Assisted Level 2 IVC TE Dr Santoshi Nagaonkar, Dr Himanshu Gohil, Dr Parth Barot P D Hinduja National hospital, Mumbai INDIA

Background: Ten percent patients with RCC concomitantly present with an IVC Thrombus (IVC-TE). The first reported series of robotic management of IVC-TE started in 2011 for the management of Level I – II thrombi with subsequent case reports in recent years.

Material and Methods: We present a case with Level 2 (Retrohepatic) thrombus in a patient presenting with right renal cancer. The tumor was clinical stage T3b with inferior vena caval thrombus. The patient underwent robotic assisted nephrectomy and IVC-TE. We followed a text book approach by using Bull dog clamps to gain control over the proximal IVC and left renal vein. The retrohepatic segment of the IVC was controlled using a laparoscopic Satinsky clamp. A real time USG is invaluable tool in assessing the extent of the tumor thrombus.

Results: Level 2 and Level 3 IVC thrombectomy pose a significant challenge even for open approach. Robotic IVC thrombectomy is equally challenging procedure, however due to improved vision and instrumentation, retrohepatic access becomes relatively easier. Our patient needed no blood transfusion and was discharged on 6th POD.

Conclusion: Robotic approach to retrohepatic IVC tumor thrombus is a feasible surgical option. A standard text book approach can be replicated even in robotic procedure.

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