453 - Robot-Assisted Radical Nephrectomy with Inferior Vena Cava Thrombectomy

SEPTEMBER 2021 | The Surgical Technologist | 401 P A T H O L O G Y N E C E S S I T A T I N G S U R G I C A L I N T E R V E N T I O N Tumor thrombi extending into the IVC are classified based on their extension along the vena cava, using a system 14 developed in 1987 by Neves & Zincke. A Level I thrombus is one which extends less than 2 cm from the junction of the renal vein and the inferior vena cava. A Level II thrombus extends more than 2 cm from the renal vein but terminates inferior to the hepatic veins. A Level III thrombus extends superior to the hepatic veins, but inferior to the diaphragm. Any tumor thrombus which extends superior to the diaphragm is classified as a Level IV. 15 As venous extension increases, so too does the dif- ficulty of resection, which in turn increases the risk of perioperative morbidity and mortality. 7 The most common subgroup of RCC, clear cell renal cell carcinoma (ccRCC), often presents with hypervas- cularity. This common characteristic raises the potential risk of significant bleeding, even in the absence of a tumor thrombus, due to the presence of well-developed collateral vasculature. 7 Though useful in all variations on this proce- dure, a robotic ultrasound probe will be essential in iden- tifying residual vascular supply after renal artery ligation 9 as well as determining the size and location of the tumor thrombus intraoperatively. Another complication which may contraindicate surgical intervention altogether in the instance of IVC thrombus is metastatic disease. Kamimura et al. (2017) noted that “Although the significance of cyto- reductive nephrectomy in metastatic renal cell carcinoma (mRCC) is reported, that of surgical intervention in cases with venous extension is still controversial because of the high perioperative complication and mortality rates.” This point continues to show how meticulous patient selection and screening is essential to surgical success. S U P P L I E S • Basic laparoscopic kidney pack • Arm positioner • Foam positioning aids (donuts, arm pads, pillows, head- rest, etc. as needed) • 15mm Endocatch bag • Vascular stapler • 5fr open-ended catheter • 10cc Luer-lock syringe (x4) • Veress needle • Laparoscopic suction-irrigator • Monopolar electrocautery pencil with smoke evacuation • Skin closure adhesive • Vessel loops (x4) • Laparoscopic cholecystectomy drape • Utility drapes (x4) • Local anesthetic of surgeon’s preference • Heparinized saline • Suture as follows: • 4-0 polypropylene suture on RB-1 needle (x4) (two cut to 7” with a knot • 10mm Hem-O-Lok and Lapra-Ty for cavotomy stitches, and 2 cut to 4” with a knot and Lapra-Ty for “rescue” stitches in the event of inadvertent vascular injury) • 0 Vicryl CT-2 (x2) • 1 PDS CT-1 (x2) • 0 Vicryl UR-6 (x2) • 4-0 Monocryl PS-2 (x2) E Q U I P M E N T • DaVinci Si robot • Intraoperative ultrasound with robotic/laparoscopic probe • Bipolar and monopolar ESUs • BAIR hugger (upper and/or lower as patient physiology may dictate) I N S T R U M E N T A T I O N • Standard Si reposable instruments (to include mono- polar scissors, fenestrated bipolar forceps, and Prograsp forceps) • Round-tipped robotic scissors • Laparoscopic atraumatic grasper • Laparoscopic needle driver • Laparoscopic scissors • Urologic open instrumentation (to include various forceps, scissors, long fine-tipped needle drivers, and retractors) • Major vascular instrumentation (to include Potts scis- sors, DeBakey peripheral vascular clamps, Satinsky clamps, Garrett vascular dilators, and other large vascu- lar clamps as available) • Chitwood vascular clamps • Laparoscopic bulldogs and applier (x2) • Robotic bulldogs (x4) • Small, medium, and large Hem-O-Lok appliers and clips (or other laparoscopic clips as available) • Lapra-Ty applier and clips