Leiomyosarcoma of Inferior Vena Cava: Resection and Reconstruction

1. Introduction

2. Exposure

1. 1. Perform Makuuchi Incision
      • An inverted L-incision was made through the skin with a knife and carried down through the midline fascia and then the anterior rectus sheath.
   2. Divide the Camper’s and Scarpa’s Fascia
   3. Divide the Rectus Sheath
      • A Kelly clamp was used to elevate the rectus fibers and divide them taking care to control the superior epigastric bundle.
      • The posterior sheath was divided and the abdomen entered laterally as well.
   4. Tie off Inferior Epigastric Vessels
   5. Enter Peritoneal Cavity
   6. Setup Thompson Retractors

3. Mobilization

1. 1. Perform Kocher Maneuver
      • The hepatic flexure and ascending colon were mobilized off their retroperitoneal attachments along the white line of Toldt.
      • A wide Kocher maneuver extending partially beneath the root of the mesentery was performed thereby completing a Cattell-Brash maneuver to expose the entire infrahepatic vena cava.
      • This maneuver also revealed the tumor and the kidney.
   2. Mobilize Right Colon
   3. Tie off Feeder Vessels of Tumor and Bleeders
      • Several small branches on the anterior and posterior surfaces of the vena cava were ligated with ties and divided.
      • A vessel loop was used to encircle the vena cava.
   4. Expose and Tie off Right Gonadal Vein
      • An enlarged gonadal vein was identified, tied, and divided.
   5. Mobilize Structures
      • The medial aspect of the vena cava was dissected free, clearing away the lympho-adipose tissue.
   6. Isolate Left Renal Vein
      • The left renal vein was identified, carefully skeletonized, and encircled with a vessel loop.
   7. Tie off Branches of the Vena Cava
      • Focusing dissection on the segment of inferior vena cava superior to the tumor, several other short hepatic veins were divided, and the caudate lobe was dissected off the IVC.
      • The main right adrenal vein as well as an accessory right adrenal vein were identified, ligated, and divided.
      • An additional vessel loop was placed around the distal aspect of inferior vena cava (superior to the tumor).
   8. Ligate Right Renal Artery
      • The right renal artery, which was immediately posterior to the left renal vein, was identified.
      • Given preoperative imaging and understanding that the right kidney would need to be resected en bloc, this artery was ligated and divided.
   9. Continue Retroperitoneal Dissection
      • Shifting focus to the retroperitoneal dissection, the hepatorenal ligament was opened and the retroperitoneum entered with dissection carried down onto the diaphragm, superior to the tumor.
      • The right adrenal gland was freed from surrounding attachments taking some vessels between clamps as necessary.
      • The dissection was extended inferiorly and the right ureter was identified, ligated, and divided.

4. Tumor Resection

1. 1. Review Progress
      • At this point, the right adrenal and right kidney were totally mobilized in conjunction with the tumor such that the only remaining attachments of the tumor were the proximal and distal cava, as well as the left renal vein.
   2. Harvest Muscle Sample for Resection
   3. Control Additional IVC Branches
   4. Administer Heparin and Obtain Proximal and Distal Control
      • 1000 units of systemic heparin were administered.
      • Clamps were placed on the infrarenal vena cava, left renal vein, and suprarenal vena cava.
   5. Resect Tumor
      • The vena cava above and below the tumor and the left renal vein were sharply divided, allowing removal of the en bloc specimen.
      • The specimen was taken to pathology and margins were noted to be clear of tumor.
   6. Place Inferior Vena Cava Graft
      • A 20-mm ringed Gore-Tex graft was brought onto the operative field to reconstruct the vena cava.
      • The suprarenal anastomosis was performed with a 5-0 Prolene in a running fashion with sutures placed at the 3- and 9-o’clock positions and then run along the back and front walls respectively. The graft was filled with heparinized saline solution and the clamp was moved off the suprarenal cava and onto the graft.
      • The infrarenal anastomosis was performed with a 5-0 Prolene in a running fashion as before, after the graft was trimmed to an appropriate length and distal rings were removed.
      • The suprarenal and infrarenal vena cava clamps were released.
   7. Divide IVC and Left Renal Vein
   8. Place Renal Vein Graft
      • A small cuff of Gortex was fashioned into an interpositional jump graft to allow for a tension free left renal vein anastomosis.
      • This cuff was sewn to the left renal vein.
      • A side-biting Satinsky clamp was placed on the caval graft after removal of the rings at the anticipated location of the left renal vein insertion.
      • A graftotomy was created on the medial aspect of the graft and using 5-0 Prolene, a graft-to-graft anastomosis was done in a running fashion—again similar to the previous anastomosis.
      • Clamps were released, and flow was assessed.

5. Closure

1. 1. Create Omental Pedicle Flap
      • A pedicled omental flap was created by taking omentum off the transverse colon and the greater curvature of the stomach and dividing the left gastroepiploic vessel.
      • This was placed overlying the graft into the right retroperitoneum.
   2. Remove Retractors
      • Hemostasis was ensured.
      • The Thompson retractor was taken down, and the abdominal contents were inspected.
   3. Close Abdominal Wall
   4. Close Fascia
   5. Close Skin

6. Post-op Remarks

7. Analysis of Sarcoma Margins