Liver transplantation techniques for the surgical management of renal cell carcinoma with tumor thrombus in the inferior vena cava: step-by-step description.

Abstract

Renal cell carcinoma (RCC) with tumor thrombus in the inferior vena cava (IVC) poses a challenge to the surgeon given the operative difficulty, potential for massive hemorrhage, and possibility of tumor thromboemboli. To determine the applicability of a self-developed technique based on orthotopic liver transplantation procedures for safe resection of these tumors. From August 1997 to February 2008, 68 consecutive patients underwent resection of RCC with suprahepatic and/or retrohepatic (level 3 and 4) tumor thrombus in a single referral institution. A triradiate incision over the upper abdomen permits the placement of a Rochard retractor. Early vascular control of the renal artery is achieved by creating a posterior plane of dissection. Venous collateral decompression permits development of a bloodless anterior plane by mobilizing the liver in a "piggy-back" fashion and the spleen-pancreas en bloc to the midline. Thrombus extraction requires circumferential control at the renal veins, hepatic hilum, and IVC before cavotomy. The central tendon of the diaphragm may be opened for cranial control and gentle traction over the right atrium performed. Repositioning of the proximal clamp and Pringle release avoid veno-venous bypass and cardiopulmonary bypass (CPB) in most cases. The extent of the tumor thrombus was retrohepatic in 56 patients and suprahepatic/intra-atrial in 12 patients. Mean operative time was 5 h 32 min. Mean estimated blood loss (EBL) was 2112±3834 ml (range: 100-25 000), with a mean transfusion being 4.2±4.1 U (range: 0-30). Five patients (7.3%) required CPB. Three patients (4.4%) died in the immediate postoperative period. All had complete tumor resection. No patient developed intraoperative thromboembolism. This surgical approach provides excellent exposure and control of the IVC in cases with level 3 and 4 tumor thrombus, avoiding CPB except in rare circumstances.