EURURO Vol. 72 No. 2

relevant number of short hepatic veins is controlled with

robotic Hem-o-lok clips and/or suture-ligation

( Fig. 2 g

Releasing the short hepatic veins is essential to retract the

caudate lobe; this maneuver exposes an additional 3–4 cm

of the IVC allowing high intrahepatic access to the retro-

hepatic IVC. The right main adrenal vein is controlled with

Hem-o-lok clips

( Fig. 2 h

), and the right lateral border of the

suprarenal IVC is dissected. Retrocaval dissection of the

intrahepatic IVC is performed. A double-fenestrated grasper

is used to encircle the IVC with a Rummel tourniquet in this

high retrohepatic location

( Fig. 2 i

). The right renal hilum is

dissected and the right renal vein is exposed.

2.3.4.

Right-sided caval thrombectomy

All Rummel tourniquets are reconfirmed to be in the

appropriate position, with a sufficient margin around the

thrombus. This is achieved with visual confirmation

(appropriate narrowing of the cava on cinching the Rummel

tourniquet) and/or a drop-in ultrasound probe.

The right renal artery is dissected and clipped in the

interaortocaval region

( Fig. 3

a). Anesthesia is alerted that

caval blood flow will be temporarily halted. The initial

maneuver is to cinch the distal (infrarenal) IVC tourniquet.

Once assured that the patient is able to tolerate caval cross-

clamping, the left renal vein and proximal IVC Rummel

tourniquets are cinched sequentially, thus excluding the

thrombus-bearing caval segment. The thrombus-bearing

right renal vein is transected with an Endo GIA stapler

(vascular load; Covidien)

( Fig. 3 b

and 3c). The excluded

caval segment is now rotated and circumferentially

inspected 360

to reconfirm visually that all feeding lumbar

veins have been secured. An appropriately situated

cavotomy is created toward the right edge of the IVC,

adjacent to the right renal vein ostium

( Fig. 3 d

and 3e); the

cavotomy should be well planned so that subsequent caval

reconstruction does not overly narrow its lumen.

The thrombus is carefully dissected free from the IVC

lumen without local spillage

( Fig. 3 f

and 3g). The right renal

vein ostium, along with its staple line, and any infiltrated or

densely adherent IVC wall are excised en bloc with the

thombus; the tumor thrombus specimen is immediately

placed in a 10-mm Endo Catch bag (Covidien), precluding

local seeding. The IVC lumen is copiously irrigated and

flushed with heparinized water. Caval reconstruction is

[(Fig._1)TD$FIG]

Fig. 1 – Patient positioning and port placement. Veress needle pneumoperitoneum is achieved, and the 12-mm camera port is placed at the level of the

12th rib in a somewhat more medial location than regular renal robotic surgery, where this port is closer to the right lateral rectus border. The rest of

the bariatric robotic ports are inserted, the most caudal located cephalad to the pubic symphysis and slightly lateral to the medial umbilical ligament.

One robotic port is placed three fingerbreadths cephalad and medial to the anterosuperior iliac spine; of note, an equilateral triangle configuration is

the goal of these three ports (including the camera port). The uppermost bariatric robotic port is placed one fingerbreadth from the costal margin, 8–

10 cm cephalad to the camera port. A 5-mm port is placed below the xiphisternum for liver retraction; a 12-mm assistant port is placed medially

between the camera and uppermost robotic port; and a 15-mm assistant port is placed distal to the umbilicus, closer to the midline. The robot is

docked over the patient’s shoulder. (a) Schematic demonstrating port placement for vena caval control (laterality nonspecific) and right-sided caval

thrombectomy; (b) operative photograph demonstrating port placement for vena caval control (laterality nonspecific) and right-sided caval

thrombectomy; (c) schematic demonstrating port placement for left radical nephrectomy following caval thrombectomy; (d) operative photograph

demonstrating port placement for left radical nephrectomy following vena caval thrombectomy.

As = assistant port; Cam = camera; Liv = liver.

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