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

SEPTEMBER 2021 | The Surgical Technologist | 403 In some cases, a Level I thrombus may be able to be retracted into the renal vein via gentle lateral traction on the kidney. In which case, the surgery proceeds much like a standard radical nephrectomy. ImageSource:HenryFordTV (2011). artery. The IVC will be dissected circumferentially using an interaortocaval approach. If lumbar veins are encountered which cannot be navigated around, these will be ligated with 10mm Hem-O-Lok clips and cut. The ureter will be skel- etonized and ligated with 18mm Hem-O-Lok clips, with two placed distal to the line of transection and one placed proxi- mal so the end with two clips remains in the body. The ure- ter then will be divided between these clips. The renal artery will be skeletonized and ligated as before, using 10mm Hem- O-Lok clips, and divided. At this point, the ultrasound probe will be introduced via the 15mm assistant port. This will be used to confirm the position of the tumor thrombus. After confirming the size and location of the tumor thrombus, the surgeon will decide whether to proceed with a cavotomy and thrombec- tomy, or if the tumor can be sufficiently reduced with renal traction, in which case the renal vein will be divided using a stapler with a vascular load as is common in a standard robot-assisted radical nephrectomy. This approach is often feasible for Level 1 thrombi and when achievable allows for a significantly less complex vascular control. If the surgeon decides to proceed with a cavotomy, three vessel loops will be passed in via the 15mm assistant port. These will be used as Rummel tourniquets on the left renal vein, as well as the IVC, inferior and superior to the throm- bus. An ultrasound may be used to confirm the superior and Improvised Rummel tourniquets can be fashioned using a vessel loop and a 10mm Hem-O-Lok clip. ImageSource:HenryFordTV(2011). The cavotomy will be made on the anterior surface of the vena cava at the junction of the renal vein. ImageSource:HenryFordTV(2011).