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

| The Surgical Technologist | SEPTEMBER 2021 404 inferior boundaries of the thrombus. The use of vascular clamps is not advised, as inadvertently clamping the throm- bus may create an embolus. The tourniquets are doubly looped around the vessels and held in place with a 10mm Hem-O-Lok clip. The order of application will be: left renal vein, inferior IVC, superior IVC. The cavotomy will be made at the anterior junction of the IVC and right renal vein, then extended superiorly and inferiorly using round-tipped robotic scissors. The throm- bus will be carefully delivered through the cavotomy, tak- ing care not to break or sever it. While being removed, the thrombus will be covered with a sponge and gently retracted with the Prograsp forceps. The cavotomy will be repaired using a 4-0 polypropylene stitch on an RB-1 needle, cut to 7-inches, using a continuous running suture technique. The tail of the stitch is knotted, with a 10mm Hem-O-Lok clip and Lapra-Ty as a bolster. Once the cavotomy repair is nearly complete, the lumen will be flushed with heparinized saline and the repair will be completed. The suture will be secured on the end with a Hem-O-Lok clip and Lapra-Ty. Care needs to be taken that the lumen of the IVC is not narrowed more than necessary. The Rummel tourniquets will be cut and removed in the same order that they were applied: left renal vein, inferior IVC, superior IVC. The specimen will be placed in a 15mm Endocatch bag and the surgical field will be evaluated for hemostasis. Once the surgeon is satisfied with hemostasis, the robotic and laparoscopic instruments will be removed, and the robot will be undocked from the patient. The most inferior port site (Arm 3) will be extended to extract the specimen. The peritoneum will be closed using a 0 Vicryl suture on a CT-2 needle and the fascia will be closed with a 1 PDS suture on a CT-1 needle. At this time, local instillation of 30cc 0.25% bupivacaine can be placed below the transversalis fascia as a TAP block for post-operative pain management. Local anesthetic then will be injected subcuticularly, and the skin will be closed with a 4-0 Monocryl suture on a PS-2 needle. The camera and 15mm assistant port sites will be closed with 0 Vicryl sutures on a UR-6 needle, followed by 4-0 Monocryl suture on a PS-2 needle. The remaining port sites will be closed with 4-0 Monocryl suture. Finally, the surgical field will be cleaned and Dermabond will be applied. No dressings are needed if superficial hemostasis has been achieved. P O S T O P E R A T I V E P R O G N O S I S The procedure of nephrectomy with IVC thrombectomy is associated with a significant risk of perioperative complica- tions including perioperative mortality. Studies of periop- erative complications have suggested a rate of 12% to 47%, depending on the thrombus level and mortality rates have been shown to be 5% to 10%. 11 The risk of complications exists irrespective of the surgi- cal approach, and to date there have been no Level I trials to suggest an improvement in surgical outcomes with robotic assistance. Observational data, however, do suggest that the robotic approach may be associated with decreased length of stay, reduced blood loss, and a decreased risk of periopera- tive morbidity and mortality, albeit in a population that is very highly selected. 1 Given the high-risk nature of nephrectomy and IVC thrombectomy, it is important to recall the natural history of RCC with tumor thrombus. In absence of surgical treat- The cavotomy is repaired using a 4-0 polypropylene stitch. Care should be taken that the lumen of the IVC is not narrowed more than is necessary. ImageSource:HenryFordTV(2011). Coordination with vascular surgery is strongly recommended, and it is advis- able to have a vascular surgeon present during IVC dissection and cavotomy, if possible, in the event that conversion to open becomes emergently necessary.