Leiomyosarcoma of Inferior Vena Cava: Resection and Reconstruction

CHAPTER 1

I'm Parsia Vagefi. I'm one of the liver transplant and hepatobiliary surgeons at Massachusetts General Hospital. And I'm Alex Haynes from the Division of Surgical Oncology. I'm a sarcoma surgical oncologist also at the Massachusetts General Hospital. Today, we're going to be presenting the case of a woman with a inferior vena cava leiomyosarcoma. This was diagnosed when she was having back pain and was biopsied and found to be consistent with a leiomyosarcoma. She underwent preoperative radiation with a proton beam radiation to 63 gray, and she's presenting today for resection of the tumor. The tumor appears to be involving the infrahepatic vena cava as well as the origin of the left renal vein and the hilum of the right kidney, and today we're going to remove it in an en bloc resection with reconstruction of the vena cava and reimplantation of the left renal vein. The operation will proceed with her preparation where she'll get an epidural catheter along with central lines and arterial lines by our anesthesia colleagues, and then we'll make an incision. I like to use an inverted L Makuuchi style incision for excellent exposure to the right upper quadrant. We'll then mobilize the duodenum and right colon in a Cattell–Braasch maneuver to expose the entire anterior surface of the vena cava and the tumor. Once we do this, we will encircle the vena cava above and below the tumor and soft, non-involved portions as well as the left renal vein. We'll mobilize the right kidney out of the retroperitoneum and divide the right ureter. We'll divide the right renal artery and free up the kidney and adrenal entirely together with the tumor to remove as one specimen. Once we have done this, we'll place clamps at the three division point to the vascular structures and sharply divide - divide the vena cava and the left renal vein. At this point, Dr. Vagefi will reconstruct the vasculature. We'll use a ringed synthetic graft and to reconstruct the vena cava, we'll first do the suprarenal anastomosis, using a continuous suture of Prolene and then do the infrarenal anastomosis. Then we'll unclamp and allow for vena cava flow to be restored. At that point then, we'll reconstruct the left renal vein either directly into the caval graft, or we might have to use a small extension of graft - interposition graft in order to allow the left renal vein to reach the caval graft. And then once that is completed, then Dr. Haynes will complete the operation with closure. I also typically perform an omental pedicle flap for these kinds of operations where we divide the left gastroepiploic artery in order to allow the omentum to be turned into a pedicle to place in the retroperitoneum to fill up the dead space left behind by removal of the kidney and the tumor and to provide some biologic soft tissue covers for the synthetic graft.

CHAPTER 2

Knife, please. So unlike for an adenocarcinoma or someone who has a high risk of perineal mets or other things, we're not going to - you don't need to do the incision in parts. We'll just do the whole thing. Now, if this were for liver or something like that, I'll often make just the vertical midline part, explore, and then finish it. This is called a Makuuchi type incision. You can use it at - on either side. It was developed by Makuuchi in Japan for gastric surgery with a leftward-swinging horizontal limb, and it provides great access for liver surgery or right retroperitoneum.

Not quite on the midline - let's see. I think that might be your side - hard to say. Let's clear off a little bit more. I think that's going to be midline there. Yeah. Good. Why don't you go ahead and get in? Sometimes from the radiation, they end up with some adhesions - more than you expect from someone with a virgin abdomen, but... Gotcha. That should be in, I think. Right there, yep. This is going to be actually right here. Probably don't need to be any higher - further up - I don't think. It's now - I'll protect from the inside. Same way - open up sub-q and then go through layer by layer.

So just go through - don't go through the rectus all at once - because we'll have to - find the epigastric. I mean, it's not the end of the world if you find it post hoc. Now, just clear off the rest of it up laterally. Looks like that's edge of rectus there. So we'll take a Schnidt, please. We'll just go through it layer by layer and... And right in there, so we'll go through that. This is the part where I get to be an ambidextrous surgeon. Should be in there somewhere. It's right there.

Let's take three ties here. Thanks. DeBakey. That's up to start. Right over there. Another Schnidt.

As you can see, the different layers coming together. It's nice abdominal wall anatomy too. So it's - we're free enough to get the Thompson in, I think. Good one guys. That's great, thanks. Get just a little bit - Bovie. I always like to take this like out here because it makes a handle, and if you really want to go nuts, you can take it long, and you have a nice - you can use it as a you know, buttress to suture lines and the like. Good, I think. Yeah.</p?

How high up do you want this? Yeah - same as yours? Yeah, so just even with mine. So the top one is the crossbar. Crank. Alright, we'll take the sidebars. So let's see. Let's start with - actually, we'll start with - on this one. We'll take a bladder blade. To the top or... To the top, yep. The construction - the reason why I like the Thompson for these kinds of cases is because you make - you make it up. You know, so you - you can make it fit what you need. Okay, and go ahead. Rotate the bed towards me, please. So now we'll start with our Kocher.

CHAPTER 3

So why don't you pick up on the - yep - on the hepatoduodenal ligament. DeBakey and Bovie. Got it. And Schnidt to me. And just bring it back, yeah - just to get maximum mobility. So we're just widely Kocherizing the duodenum here to expose the vena cava and the tumor behind it. Great. Schnidt to me. This is going to be our plane of dissection right here because this is the anterior surface of the cava that we're seeing here sort of ballooned out by tumor, and I think we're already over to the left side here - yep. Okay. Yeah, we got to get through all that too, which is sometimes easily - better done with just the finger. This is a little bit different than doing this for Whipple because we're going to keep the duodenum, so we need to be gentle with it. Yep.

So I think we're starting to see that gonadal that we saw that was so enlarged. I think that's what we're saying right there. We probably need to mobilize the right colon just to get it out of our way. Sure. But as you can see, it's not in any way stuck to the tumor, so we definitely will not need to do anything to her colon. Sometimes, it's hard to tell from the scans if things are just abutting tumor or stuck to it, but this is clearly - was an abutting. We're going to need a packing towel. That's more or less a full Cattell-Braasch now. I mean, I guess, technically, didn't - you'd take it all the way down to the cecum, but I don't think we need to do that - I think we're pretty far over already. Get this just a little bit more over. All the way over the aorta here. Let's just get all this over. Just do all of this because we really want just all the viscera over on the left. Actually, it almost just stays there on its own, doesn't it? You have a right angle to me? Here you go. Yeah.

So this is some - I probably need to tie that. 3-0 ties, please. Three. Another tie. A lot of these who tend to be fairly parasitic. So one thing we didn't talk about with her, Jahan, is she got pre-op radiation. She's on a protocol that we're doing now with using protons through our preoperative dose-painting of the high-risk margin, and so she got - instead of the 50.4 gray that we typically give to retroperitoneal sarcomas, she got 63 gray, using protons that provide a - you know, sort of a - a preemptive boost essentially to the high-risk margins, so that's why we're not doing it in the intraop radiation room. We often will use IORT on these patients. Metz, please. You have it? I've got it, but... Ready? Suction. There's something else still going there. Dry lap, please. Metz. Another DeBakey. Suction. Yes. Another right angle. Can you suck in there, Lauren? Do you know? Did you get it? Nope. It's just anterior to something up. Put a stitch in it maybe? Yeah, can I get a - you know, like a 4-0 Prolene? Let's go ahead and tie these other ones. Sure. I'll hold it. Let's start with 3-0 ties. You know, normally, there shouldn't be a bunch of anterior branches of the cava here, but since there's tumor, all the bets are off. Stitch. Let's just get nice and clean. Go ahead and take that. Needle down. Squirt my hands. Thank you. There you go. Alright, so let's get that cleaned up a little bit.

Alright, so let's go ahead and get the gonadal out now I think. Right angle. Alright, Schnidt, Schnidt. We'll probably want a 2-0 silk stick tie, please. Uh, actually, I'll just use the right angle for the top half here. Metz. Metz. So that's the gonadal vein - quite enlarged. Like we did the caval obstruction except... Suture scissors and then I'll - they'll cut. Another tie to us. Actually, a stick tie. So we'll find the ureter back here. That's - that's it right there. We take it. That's - that's nice soft surface of cava there, so that'll be a perfect in our - that will be a good transection point right about where we put that stitch. Cut the needle, please. Needle back to you. I'm sure a free tie would have been fine, but just because it's so big. A little squirt of irrigation, please. And a dry lap. Awesome. Thanks.

Well that portal structure, which we want to kind of peel off the tumor. See those retroperitoneal collaterals - you know, this right there. It's a lot more than what we usually have back there. So I guess we can get our retractor down under here and start opening up that space. We'll have to figure out if we're going to need to mobilize the liver anymore or not. Let's get this out here. Sometimes, once you start getting behind the liver, you start finding direct branches of the cava to the - to the liver, so we'll keep our eye out for that as we start heading north. And that looks like a little - a branch there? Yeah. Go ahead and open there. Yeah, or tie it. You want to tie it? Right here. Why don't you go ahead and take a feel? Yep, kidney's there - all the way back to there, yep. So we need to get that up of course. Sucker. There's a place to get around it right there. Okay. Alright, so let's keep coming back - open up the lateral side here. Right angle to me. So why don't you take the tumor over towards you? So this is all that aortocaval nodal tissue, but this is going to be our left right there - I think it's going to be left right here, and then that's going to be vein, cava. Right angle, please.

Alright, so now - so that's - that's left renal vein. It's interesting. It seems very, more - I guess there's tumor right there. Behind it, yeah. Yeah. Sort of ends right there. You mean, right there. So this is probably, again, a pretty good spot. Let's just keep... On the other side. Let's keep clearing this off a little bit more. But, you know... Some stuff you want to grab and burn or something like that - that's just, you know. DeBakey, please. Just that lymphatic tissue that can be annoyingly oozy. Dry lap. Another little branch right here, right? 3-0 ties. Especially, prefer to not to put a lot of cl - you know, if possible, not put a lot of clips on this, you know. Another tie. Well, this - this is all - probably all going to go here, but... Actually, a - just a blue clip to me. Suction. Good, and up. Okay. Yep. You probably have a good shot with your right hand. Alright, can I get a right angle? Do you have a vessel loop, Lauren? Do you have a - clamp? The Vagefi clamp. I would probably try and put it through with a minimal of spreading. Sure. It's sort of like - it's sort of like doing the - tunnel on a pancreas. Vessel loop. Loop. Is this long? It is long. Fantastic.

Alright, so now I've got the left renal vein isolated. Let's - let's go ahead and do - do the inferior border here. DeBakey. Bovie. So this is nice and soft all through here, so I think... We get around right here? Yeah, so why don't you take the right angle? I'll take the DeBakey, so - so we do - I mean, we've got plenty of exposure here, so let's do it under vision. DeBakey to me. You want me to go around now? You will see - see it. You want to clear this edge off? Just clear it off a little bit, yeah - just, I mean, because, you know, there's no reason to go through there blindly - because we have it so cleaned up. Bovie to me. And we've already found anterior branches that we weren't expecting, so... And posterior branches are a bigger pain in the butt. Bovie. Good, up now. Does that go around? Yeah, why don't you - want to come - let's take a little bit on this side. Let me get the suction and just clear it out for you. Yeah, so do you want to you want to get around the cava or the branch, first? So we can get around the cava proximally. Yeah, and then we can lift it up and then decide what to do about that branch. I mean, if we don't need to take it, we can leave it. Yep. There's another small branch on my side. A little - just a little bit deeper, yeah. There you go. Actually, you know what? There's a small branch right where you're coming out - woah, vessel loop. Just south of you, there's another one of those little ones. Alright, infrarenal cava. Do we have another posterior branch there because I thought I saw a large... Let's see. Yeah, right back there. And then the question is - do we need to take it or not? And I don't know if we do. It's probably... This is probably our clamp right. Yep. That leaves enough room to sew. Let's leave it for now, and if Parsia wants to take it to give himself more room to sew, then that's fine.

Alright, so now, let's see - is - can we get the renal artery here? Should be directly behind that vein because of the scan, so... Yeah. Clear this edge off here. Yeah. So let's see. I wonder - let's see if we can get - let's reposition this now as you got that all over, see if we can get all this. Yeah, so there's aorta. Let's clear off actually the top part of here, I think. I don't think we've cleared this off very well, yeah. So why don't you take the tumor towards you? Bovie to me. Is there a branch in there? Or is that just - I don't see anything yet. She actually has less sort of radi - radiation edema and scarring than I'm used to. I think we waited a little longer on her just for - out of scheduling reasons, and we usually wait a month or so after the completion of radiation to start for surgeries.

Yeah, a little branch in there. 3-0 ties, please. It's just - however, you know - I got this. However much of a pain it is to do all this, it's better than just chasing little bleeding stuff over and over again. These are just direct caval branches to the liver. Yeah, I mean, because we're - you know, we're really right underneath the liver, and another way of approaching this would be to totally mobilize the right lobe of the liver and come at it laterally. But - ultimately, I don't think that's going to be that helpful, and by doing it all in this one exposure, it's going to make it - the rest of it that much easier. Why don't you go ahead and tie this one? I can put another retractor in there and get - it might be helpful. Let's get a moist lap too. So put it like that maybe. Go there. Yeah, that's good. Okay. Yeah, that'll allow us to get the cava out. Right angle, please. Let's re-adjust this. Still 3-0 tying? Yep. You can see we're - there's tumor. This is soft normal cava above it. Here's soft normal cava below it. Another tie on a pass. There's all these little tiny branches. Bovie me. DeBakey's. There's free edge there. Right angle. You can just go ahead and separate the inside of adrenal from underside of the liver. Okay, let go. Suction. Why don't you gently come ar - I think we can come around here, I think - Get enough space cleared off. Okay. Now, let's go back for that renal artery now that we've got these two. I think we should be able to find it either by doing this or the other way. See if you can feel it and get a sense... Definitely on aorta, obviously, but it's hard to differentiate whether there's a renal artery pulse. Yeah. So, alright. We just have to mobilize more on that side. You can mobilize a little more. Can I have a peanut? And a pickup to me. Bovie to me. You know, let's just get a little bit of this cleared off, and then we'll get that branch. I think I've got something in my hand. Why don't you buzz me? Can you buzz him? It's right - right there. In your right hand? Hang on - my left hand. Okay. Nope, that didn't help - made it worse. Suction. Yep. Long needle driver. I don't know if it's a second branch or if we - we tore the crotch of... Make sure that end's straight. Can I have a finer needle driver on this side? Let go of that end, please. Alex, can you pull that for me? Yep. Get suction. I'll hold it. Sure. Cut that needle off. One more tie. Wet my hand. Wet, please. Right hand. Can I have a blue clip? There's a little tear in the vessel - little proximal one in there. Alright so now, let's get a little higher up here. Right angle to me. Bovie. This is the end of the tumor here, I think. Yeah. That's artery right there. Why don't you go ahead... Check it out? Yep. Okay, can I have a DeBakey and some Metz? Can I have the long Metz? And there - there it is. We can go ahead and take that soon. Can I have a long right angle, please? So we're going to take the right renal artery. It's always nicer to take that first, obviously, not always possible, but - we also can just tie it and then finish it later once we have - once we take - you know, but we'll see. When possible, I like to do this before taking either the ureter or the... You need another one? Umm, sure. We may have enough space to really take care of it now. Suction. Retract that tumor over. Dry lap in. Give me a large clip, please. The renal artery has always amazed me because it - you know, that they're such a critical thing, but they're not big. No. They're already out of the way. Another large clip. Or are you okay with that? It's fine on the specimen side. I'll take the Metz - big ones. The right renal artery is out. Or well, the - the lateral retroperitoneum. Make sure you get all the - you can go a little - get - get the - all the lap up under the fingers and most of it - yeah, perfect. That's great. So now we're separating it. This is the hepatorenal ligament here. So now I've got my hand all the way behind the kidney. So let's t - let's - let's free it up inferiorly. A right angle, please. We're quite a ways away - away from the tumor here, so this isn't - you know, I'm not worried about margins or anything. It's different when - you know, if it's like a liposarcoma or something where you're... And we also should remember that we may find some more of those enlarged collaterals here - more than you would ordinarily. And there's the fairly free shot. Ureter's going to be right in here. We dissect it and find it. Let's get this - small bowel is - wants to come out and play. If you're doing this for like a - I don't think it's a miss, but it might be. This is - just Bovie it, I think. I don't think it's in there. That's too lateral. And, you know, unlike in like the other disease process, there's no reason to try and take it down low. Sure. Ties on passes, please. Metz first. So right ureter's out. Ordinarily, that's a fairly free shot, but... So we connect this with this. How about a Schnidt? We'll take a Metz next with 0 ties on long passes. DeBakey. So now, let's see if we can get this to come down a little bit more. Buzz right there. Big sucker. Dissection points will need to come back here. A Schnidt to me. May be some small branches in here, so don't - just because I'm showing it to you, don't buzz it. Yep. Sure, just tell him everything is going great and moving along. She is doing great. Okay, so now we can come through some of this stuff. Sounds good. So right back onto the retroperitoneal musculature here, which is perfect. That is the plane we wanted to be in. Yep. We're high enough up that we don't need to worry about femoral nerve on this - it looks. Adrenal attachments. Yeah, I think so because we're actually very close to ready for him. Taking this off. So just invade from the top? It's just we've got the cava all the way up there. Do you want me to go through? Yep. May be some branches back there, so. So that's actually pretty free there up to the left. So there's probably a few more bits we need to get above. Let's see. If you come here, that's - you know, right here, you free up the adrenal. Oh, Schnidt, please - not the giant one - the next one down. No, not at all, because this tumor is relatively posterior, so I think it's coming off the - either the posterior wall or the cava or the right renal vein. So what was pushing the duo up was the anterior wall of the cava, so it just came right off - same with the colon, yeah. Yep. Just stop back here. That needs to come. I think this is just crap. Yeah. Right angle, please. Alright, is this something we should put a couple of blue clips on?

CHAPTER 4

Alright so where's Jahan? Jahan? You want to - you want to see what we're doing? Yeah.

So alright, so we see here we've got cava above the tumor - okay - left renal vein - cava blow the tumor. We got the right kidney totally mobilized. We've taken the ureter down low. We got it up off of the retroperitoneum, and there's the - the - the right retroperitoneum. We got it free, and actually I have my hand here completely underneath the cava. See? And we've, you know, freed up a whole bunch of like little tributaries there, so basically we're ready to get the thing out. So we'll clamp the - where the vessel loops are and then take a pair of scissors, cut those out, and then the resection's done. And then we'll put in a tube graft and then implant - do a side branch to implant this, and so…

I think maybe we'll take a little piece of abdominal wall muscle. I think this is - this is totally free here. I don't know. Is there anything? And it's really pretty much just cava, I think. Maybe a few little bit of schmutz right up here, but alright, let's get that piece of muscle for the lab. Yeah, let's take this out. let's see - maybe just this little - little bit of rectus right here. Do you have an Allis? This will be like one square centimeter basically. Should I page Michael that we have a specimen coming out? Matt. Yeah, page - page Matt and just tell him we'll have it - we'll have his muscle specimen for him right now. So this is not going to pathology. So - yeah, we call it a portion of right - right rectus. So why don't you get scissors and cut it out? I don't know what - I don't know what it is that they're doing with it, but no sense sending them something that's cooked. Actually, can I have a big - do you have a silk tie? You want to just cut it off? Sure, yeah. Scissors to me. Alright, here's your muscle. Sounds great.

3-0 Prolene. Well, 5-0 because it's close to where he's - where we're going to clamp. Let - I think you can let - I think you can let go. Maybe not - maybe not. Actually, come in and pick up... DeBakey's. It's actually right there. Close by you? Yep. We were bored waiting for you, so we just kept going. This is stuff that will be much easier - you know, it's the schmutz behind it that once the cava's cut, it will come out, so it's pretty much totally free except for... Is there a lot of left renal? Eh, maybe like right at the origin there's some tumor there, but it's very soft - quite proximally - or distally if one wants to be totally pedantic about it. Yeah, don't you think? Alright. Is this the - yeah, sure. Scissors. Wet Jahan's hands. I need another 5-0. I think we can maybe take this jut off. Take the - that one, yeah. I think so. Nope. 3-0. Can we wet him a little closer to the tip? So this time, so - so, you know, put it through again. Don't take the needle off. We'll take the juts off, and we'll take a look and see if... So why don't we take first the proximal one. Through this. Take this one off. That looks pretty good, right? So then take this one off. You happy? I mean, it's still alright here. I'll hold it up. DeBakey. I was looking at that as we're doing it and thinking, "Hmm... Maybe I shouldn't be so flip, but -" goes to show. Yeah. Scissors. Good. Another stitch to me. So we just had a little bit of bleeding. Okay. The accessory adrenal vein that we got into. So I'm going to take the jut off now, right? Yeah, you can go. Can I get the - that DeBakey, please? Perhaps I can show you a little better. All out. Is that good? Yeah, that's good. Alright. Squirt my left. Alright, so I don't think there's any reason to take anymore. There's - there's like a little bit of schmutz back here. Yeah, her cava feels plenty full, so I don't know... So to make something else bleed, we'll purse this. And this should just be lymphatic crap. Okay, and the last little bit there. Alright, so. Think we're pretty much totally free. So you took the right renal - yeah, ever - everything. All you need to do is cut in three pl - places and get it out. Peanut. Small right angle. 2-0 silks. Let's take a couple of these short hepatics to get a little bit more length on the top. Yeah, we took one or two already, but got to leave something for you. Yeah, this one - I mean, you know the - this one is so posterior that the - the Kocher was easy. It was normal instead of the last one where it was all - that was just terrible. Can I take the peanut back, please? Got it - up here. Suction. Pickup. Fine. Can we open up the graft? Small clip. Another clip. On this side. Yeah, just dip it in water - saline. Can you give her a thousand of heparin, please? And I already just occluded my fingers, and... She did okay? Didn't - didn't blink.

1000 heparin is in. Hey Jahan, you want to be over here? Sure. Yeah, why don't you come over here? You have white towels? You have heparinized saline?

You have the three? Alright, ready, Jahan? Ready. We're going to clamp the cava. Okay. Peanut. Never mind - too late. Push that back. Scissors. Big sucker. Got it. That's right. There you go. Here's the tumor. That, I think, is just pushing through. Yeah, I think so because this is like normal vein there. When it was John, they like - totally lig - they pushed it through all the way, and they're like - do think it's - it's all just positive, so... Yeah. So this is going to be right retroperitoneal sarcoma. How's she doing? With IVC, right kidney, kidney, right adrenal, and portion of left renal vein.

Can we get the graft, please? Right renal, you said? Left renal. Alright, I'll take that over to path. Is this for frozen? Yep, and I'll take it, I'll take it, yep. Shod. Another stitch. You crease it the whole way like that or just... On the back wall, try to fold it and make it nice and smooth. Shod. You want me to follow you and hold the graft? You're going to follow me in a second. Let go of the graft. Just follow the stitch. Actually, hold the graft in the other hand if you want. Yeah, that'd be great. Get ready to squirt. Relax a second on the graft. You're going to have to cheat a little bit more on the graft. It's a little bit bigger obviously. Travel a little more on the graft? Yeah. Load up. You can take it off. Load it up. Squirt again. So I'm outside. You're outside. Just come outside on the top, outside in, then inside out on the graft. So outside in on cava, inside out there. Either - well, you can go... Doesn't matter to me. Whatever is easier for you. Do you want me to creach it too, or...? No, just come in. It'll be fine. This you can just take, you know, straight across. It's fine. Pull up. Pull all the way up. Yep. We're going to need heparinized saline on maybe like a Asepto if you have it. Sure. Can I get another Asepto? We'll need a marking pen. Don't want cava. Just where that short hepatic tie was. Short hepatic tie was, yeah. Do you have another clamp? Pickup, please. Small clip. Hold the graft. Marking pen. Heavy scissors. Oh, so you don't want it to be too long? Yeah. Heavy scissors. Can you save that piece I gave back to you? 5-0. Now we'll do the infra. So I cut this, I spatulate just to make it a little bit wider - make up for the - little bit of the size discrepancy. Shod. Stitch. Shod. Tie that one up. Squirt them. Right or left? Right. Actually, left - to the left. Squirt more. Empty to him. Squirt. Do you want graft to cava or cava to graft? I can do either side, so it doesn't matter. Why don't you go graft to cava? Okay. Shod. Can you airplane the table towards me a little bit, please? Do we know the clamp time by any chance? Yes, you clamped at 19 past. Scissors. Heavies? Yep, a little bit more. Travel more on the graft. Come back on the cava. Come back this way - not only back this way but back towards your last stitch. Yep. You're going to come out of that corner again. Right here on this one. How did you secure the right renal artery for it to be reinforcerd or...? It is tied with a - with a 0 tie and large clip. Okay. We'll need heparinized on a Marks. Do you want to shod the other side of that? No, we're okay. Come cava to graft. Get ready to squirt. I'll take the heparinized. Got it. Good. Needle down. Squirt - a lot. One second. Nerve hook. Don't break it. Scissors. Squirt left again. Two needles. Okay. Ready? Want me to pull back to you? Cava is on clamps. Can I see a stitch? Pickup. PD sucker. Needle. Peanut.

What was it? Want a Gerald? Yeah. Let's just dry it up towards the renal vein. DeBakey. Pickup. Renal artery this? Yeah. Or something next to it. Pickup. Yep. Bovie to my left hand. Large clip. Let me see this for a second? Hold this medially. Clip. Yep. Take it anyway. Bovie. Here's a node. You can save that for Alex if he wants it. Do we have a location of that? Clip. It's like periaortic - maybe. Let's see. Yeah, periaortic. I'm ahead of adrenal. Did you take - kept it on the kidney? Yeah, most of it. Lap, dry. Alright. Let's see what's back here. Something's oozy. You have a DeBakey, please?

Pickup. Question is if this is going to reach. Peanut. Barely. Too big. You can roll it. Longer? Does it need to have... No, no rings. Okay. You just need length. Scissors. That goes there. I think that will reach fine. So we'll close off this. Can you just splay out the renal vein with one pickup? Let's just see how wide it really is. DeBakey. Yeah, that's good. Okay, he'll take a 5-0 Prolene. Just oversew this. Eh, not - a little bit closer to the edge, yep. What do you want for that anastomosis? Well, we're first going to do graft to renal vein to extend the renal vein out, and we'll use... Do you have 5-0 on a smaller needle? Sure. Alright what... And then we'll do graft to graft with the same 5-0's. Is that good or do you want more? Huh? Do you want one more, or is that good? One more what? I'd prefer it without the knot. If - I can give you an RB2, a smaller needle, but it's going to go down to 30 inches. That's fine. Okay. I'll take that. I'm going to need five, please. We'll need two of the RB2 and then - come back to this. And then two of the RB1's again. Actually, let me see the RB... 2? Let me see the smaller needle. Yeah, we'll take - why don't you open up 4 of those - of the 5-0's. Empty. Snap. Give me another shod. Thanks. Pickup. Follow it further away. A little tear in the renal vein there. Least thinned out. These are the fine blues, right? Yeah. The non-blue ones? Squirt. So you're going to go graft to renal vein from bottom up. Is that okay? Yep. Is it lifting? Here you go. We'll get exposure for you in a second. Okay. Hold that. Empty. Squirt again. Do you have a thin malleable? Yes, please. Can you hold this maybe for us? Right there. Perfect. Thanks. Scissors. Tie on a heavy. Needle back. Squirt. You got to change that. You want - want to switch something over to him? Scissors. Needles. Yes, thank you. Can I see a Schnidt, please. Heavy scissors to Jahan. Here are some rings. Cut all that. Okay, let go. Yes, I needed a smaller needle. Yep. It's not... These are so thinned out. Cava's really thinned out. This is the end where your hand is here. Sorry, what did you say? I'm just saying cava's really thinned out there. Do you want me to rotate the graft or...? No, it's fine. And so what we do is - needle hole or? Hmm? Make that with a needle hole or a line. Save this, please. Squirt. Let me see that again. Here's your sucker back. Okay, can I see a Satinsky, please? Like a medium. That was our line right there. This is going to be here. Satinsky. Nope. Just try to partially occlude this. We're - we're clamping our graft a little bit. You probably won't notice anything, but just letting you know. Thanks. Give me an 11 blade. Those 5-0's. Amanda, I'll take three more. Knife down. Pickups. Heparinized. Whatever you've got, yeah. Scissors. Stevens. Or let me just take the knife actually - will probably be easier, this angle. 5-0's. It's just partial, and we should be off fairly soon. Okay, just let us know. We have plenty in the room. We're ready. Shod. Another one. Alright, so you want me to sew top down? Just hold there somewhere. I am not in Churchill right now. Squirt. So you can backhand it if you want, like that - might be the easiest - or forehand it - whatever you want. I'll forehand it back to you. DeBakey. Don't lean on the clamp. Not like it's an aortic clamp or anything. Scissors, please. Anything. You can pull that sucker out. Can you clean the tip of his driver? Yeah. Is that better? It's great, thanks. If not, you can try the other pair on this one. There hasn't been much blood. Yeah, exactly. Scissors. Squirt. If there's a long one in here, you can save it. There should be four there. Okay. Cava is fully open now. Needle hole? Yeah, it's all needle hole. If you have some Surgicel... 4 by 4 or lap pad - something. Another piece of Surgicel. You have a vein hook? Put all the - right there, yep. Okay, come out. Uh, the adrenal thing. Pickup. Alright, it looks like you guys are about ready for me. Almost. Alright. Just drying up. Rotate left side down. Squirt. Scissors. Needle. Are you happy? I think it looks pretty good. Scissors to me. That's the aorta, Jahan.

CHAPTER 5

About to close? About to close. We're - we got - we'll do an omental pedicle flap. We'll maybe take - we'll take a look at the gallbladder, and if it got banged up, we'll take it out. If not, we'll leave it in. You taking out the gallbladder? Probably not - I mean, unless I look at it and, you know, it's ratty from retractors, but... We worked on it a little bit. Alright. Well... I like to do a little omental pedicle because there's all that dead space back there and everything falls right back and... Bovie. So you don't need to go back there. That's the other side. A Schnidt. She doesn't - she's too skinny to have too much omentum - I know. I was going to say... But that's alright. We'll take what can get. I don't have my headlight on anymore, but... So we'll take it up here. Right angle to me. This is probably a clamp and tie. Yep. Go ahead and buzz that. Metz. 2-0 ties. Yeah. And then we'll need some 3-0 Vicryls and a couple 4-0 Monocryls. We'll saddle her I guess. Yep, half inch series cut in thirds. Open with that. Okay. Schnidt. This is the part where we have the ligature. It's a nice adjunct. So we're doing an omental pedicle flap here to kind of fill in the dead space from everything we took out of the retroperitoneal. Okay. Metz. Trying to keep her small bowel out of back there and, you know, protect the graft a little bit. So we took - took the omentum off of the colon, and now we're taking it back up to the - need white towels for that, huh? I know, seriously. Not take little tiny bites. Let's just open this up - just - just score just - just a little bit there. Yep, perfect. Can I have a Kelly? Take 0 ties for the next ones. Another Kelly after this. We're making it look good for TV. Yeah. Leaving another hole? Why don't you come out? Okay. Just go ahead and clamp it down. Get the other one, and put it on. Another Kelly. It's right in front of you. So I've got - I've got it open for you - just a little bit deeper. Yep, there you go. Alright. Metz. 0 ties. Suture scissors, please. That's a big giant wad, so... Yep, and then a tie. And then you tell Jahan when you're - you have it down because it's a - you have to... Can I have the heavy scissors, Lauren, so we don't... Yeah, they're up there. Dull up the already dull Metz. Yeah. Okay well, you're not going to be the one that makes it better. Alright. So now, let's see. So we can go in this space right here. Go ahead and buzz on my finger. Okay, Kelly's. Can I have a big right angle? Just being a little bit... Do you want to try and go below me or - no, you got it. Metz. 0 ties to Jahan. 0. What size? On passes. It's the last one I have. As you're up and out of the wound tying. Okay, cut. Okay. Large right angle. Metz. 0 ties. So now we've got the omentum living off of the right gastroepiploic. We'll free it off of the greater curve to - flop down into the retroperitoneum. DeBakey. Let's see. Do we want to really - do we need to go that close to the stomach? Yeah. I think that's epiploic right there. Yeah, I'm just trying to decide - yeah. Yeah, that could - that should be free there. Amazing, these patients with like normal-sized - human-sized... Normal anatomy? Yeah. So why don't you - Jahan, why don't you go ahead and dissect that off of the greater curve there. Can Jahan get a Schnidt? Schnidt, please. The thing you want to be careful about here is not putting the Schnidt onto the stomach itself. No. Yep, you're going to go that way. Good. Hold it open for me. Okay. 2-0 ties. 2-0's? Yep. Give yourself a little more tail. Try to tie right under the clamp. It doesn't matter where, you know, but just in general. Another tie and a pass. Try not to pull up when you're tying, so let that sit. There you go. Good. Again, it doesn't matter as much for this, but - same way every time. Practice it now so when it does matter... Another Schnidt. So when you're tying off those short hepatics that we were doing earlier, you're not pulling them off because... They will. Other hand. You want the instrument in the hand of the tip that this is pointing to. If it's pointing to your right hand, put it in your right hand. Okay. Yep. So what I'm doing here is we're doing a omental pedicle flap. The radiation oncologist loved this because, you know, if we had to give additional radiation or if she had a recurrence, this keeps just the small bowel away from the retroperitoneum. So what hand is it going to go in this time? Right hand. There you go. Good. Pull. Now before you start yanking on this, give yourself enough length there so you're not sawing. Yeah, exactly. Yeah, especially with these braided sutures - you really can saw through things. I don't know that we need to do any more up here. I think we can probably finish taking this off the colon. Don't burn the colon. Could you take one of these stands away? Can I have a DeBakey, please? I don't know where... We're a little off plane here somewhere. So this needs to come - Bovie that. I think we're - I think the omentum is stuck to her mesocolon back here for some reason because it's one spot. Yeah. So here's the plane. Because - yeah. I'm down here in the bare area. Go through that. I think that's okay. It's good practice. Go ahead. Through here or over... Right on my finger. Keep cutting it down here. Can I have a DeBakey? Can I have a DeBakey too? And a medium clip. We may not need anything more than this. We'll take a look and see what goes back there now. I'm going to be right... Right under the clamp, yep, because you don't want to tie off anything that doesn't need tying off. So let's see. So where do we tell? Let's - let's - what is going on? So this is the plane here. Yeah, something like... Separate this. Do we still have - so here's that vessel. Because we're stuck, this is omentum. This is transverse mesocolon. Yep. DeBakey, please. Right, just open up right there. Yeah, so it should be right here. Schnidt, please. See how the fat's different? Smooth fat - between the omentum and the transverse mesocolon. Yeah, there's smooth fat here. There's like this... It's probably from radiation. That's why it's stuck. Good choice. That was the most important step today. Suture scissors. Alright. So, down to there. This stuff here, yep. See right there? Right - yep, right there. Okay. DeBakey to me. Oh, I see it. It's starting to separate. Yeah - yep. You want the lumpy, bumpy part to go toward you. Exactly. Okay, stop there. That's really omentum there, but here - wait, you see this free space right there? Yep. Probably - Schnidt. Metz. 2-0 ties to Jahan. So my side first. You started right in the middle, but that's okay. Go ahead and take it. Now get rid of your forceps. Pull up on two ends. Give yourself enough slack. Good. Now come towards you. Yep. Yep. Okay, pop off the needle for yourself. You can let go of the loop. Yep. Needle down. Pull up the two ends. Good. Okay. So now, let's clean up back here. A big sucker - got it. Now we can take this. Put this... On the graft. The corn falls back with it. We're happy. Woah, that is so cool. This is weird. What's that from? Well, I don't know, but maybe actually blood supply. It's actually like this. Yeah. That - that's fine like that. There we go. Yep, leave her the way we found her more or less - minus one tumor. Okay, we've got - that's for you. Thank you. Alright, great. Let's take a look at the gallbladder. I think it looks okay. Yeah, it looks fine. Any stones in it? No. I think I'll leave it. Can't justify taking out. Yeah, no - no real reason to take it out, huh?

Alright, let's... So do you guys really need a NG Tube in? No. What kind of retractor is this? This is the Thompson retractor. You're way ahead of me because you saw this as an intern. That's the first time I'm seeing this.

0 Vicryls. We're - we're going to use the 0 PDS, but we're going to use the 0 Vicryls first. So is this to try to bring together the corners. Yep, exactly right. So I'll take a 0 Vicryl. And a Bonnie. Bonnie right there. Great. Again, this is going to go to here. Okay. Right at the corner. Right there. So this is going to be the next bite just around the corner this way. Okay. Then we're going to do the next bite around the corner towards me. This is the - both to line things up and to reinforce because this is the sort of most vulnerable part of the incision for hernias. Make sure you're seeing what's underneath and not stabbing random things. So then the next - last one here is going to be the lateral edge of rectus sheath. Can I have a Rich, please? A what? Which is right here to right here. Okay. I'll take a Vicryl, please. You can probably pick this up for yourself. You want to find the corner - is that corner right there. We actually don't have very much lateral to that on her. Sometimes, you have quite a bit more lateral. Okay, so find that corner I got... Grabbing these down there. So you know there's muscle here. Yeah. Snap. So what we want to do now is we want - close it - we're going to close the - the rest of this in two layers. Layer one is going to be the - everything but the external oblique here. Do you have a Kocher? It's coming down, see, through this. Yeah, this is rectus. That's the muscle. That's the - yeah. Yep. So we just need to start our 0 Vicryl, and this is your - your shot, Jahan - your 0 - 0 PDS. It's just going to be a couple bites, and then you're going to transition onto the posterior rectus sheath. I'd probably take just the posterior with this bite, Jahan, because it's already starting to separate and we want to save the anterior for the next layer. You want me to tie that Vicryl now? Yeah, he will take this Vicryl and goes behind. This is - I go basically just to the first Vicryl that you come to, and then you cut one, take it to the other side, and tie it to itself, Jahan. Okay. Yes, so see we're - we're a little bit - you got - need some very small bites on the top and bigger bites on the bottom - or small travels and bigger travel. And then whenever you're tying a loop, you always want to make sure to tighten both arms of the loop because you can have slack in there that you wouldn't know if you didn't tighten both sides. Okay. That's just for the first throw? Well, I mean, really with any throw, but once you do it with the first throw, it should be even for the remainder. Alright, so then anterior sheath here, midline here - tie those two in the corner and... Do we tie these Vicryls now? So - I usually don't tie - I actually tie those last usually because - you happy? Yep. Alright, thanks. Thanks, Jahan. Nice work.

That's good. Hang them on this side. Now you can actually see the fascial edge there. Yep. You want to go all the way back. Yep. Skiving through the muscle, perpendicular on the fascia. Over on this side, lift for me. So there it is, right there. Sometimes, it looks like muscle, and sometimes, it looks like itsel - like something unique - you know, like - right - distinct from the muscle. So here, let me show you something. Yep. Let me show you something. If you grab - come out. If you grab just... Can you guys page me when patient's awake? Yeah, sure, will do. Just that - see you just have the fascia there, okay? Yeah. Hang on. Got a dry lap in here - see what we're doing. Just the fascia - there you go. Good. Take just the fascia. Good. Yep. Good. Okay. We shouldn't need the light anymore, so just as long as everybody remembers not to - okay, good. So now do you see how that closes the fascia up around the muscle? Okay, good. Now, find the fascia on that side. Let me help you out. So now you're back to midline, so you - you don't have an anterior or posterior here anymore, right? It's just - yep. Yeah, it's just one piece, so go ahead. Go through it. Right there? Yep. Pull it up. Hang on. Alright, loop PDS. So now we're going to close... Anterior sheath. Anterior sheath and run it back to the midline, all the way over there through the loop. Pull it up. So, get this out of here - without spearing myself. That's back to you. Okay, Jahan, pull up on that with me. Okay. Hang on. Okay. Good. Alright. Now... Snap and scissors. Yep. Cut these off over here. Can I have scissors, please? Okay, tail. Alright, let's pull these Vicryls up and tie them. Cut. Don't cut your snap. Alright so, this feels good. I don't feel any hernias. This is closed all the way back. Can I have some dry laps? Alright, the fascia's closed.

So Jahan, a little lower than deep dermal. I don't want them to show. Okay. So I'm going to put this corner one in. You can travel more. I would do - put the next one here. Thank you. Take another stitch, please. Jahan, hold that open for me. A little flap. Yeah. Where is - I need like two more over here. Scissors. Thanks. Okay. I just need one more. What do you have to run the skin, Monocryls? You have like tons of Steri-Strips? Yeah. Do you have benzoin? I can get it. Thanks. Needle down.

CHAPTER 6

So we were able to complete the operation relatively smoothly. We were able to obtain clear margins on the vascular division structures, and we test those with the intraoperative pathology. The tumor came free of the colon and pancreas quite easily, which isn't always the case. We were able to get this operation done with relatively limited physiologic disturbance, and the patient is going to a regular hospital bed today. We did not give any blood transfusions. She is extubated and breathing on her own.

CHAPTER 7

Hey. I got a frozen for BST. Hi. Welcome to Frozen Lab. So we've got a caval sarcoma with a kidney and couple other things. Oh, wow. Sweet. Patient have a history of IVC sarcoma or...? Yeah - yeah, it's a primary IVC leiomyosarcoma. Great, now can I get some more Chucks? We're out. Sure. Wow, look at that. That is a nice looking sarcoma. Yeah, so basically we're looking to - I want - there's a couple of things I want to look at here. You want margin, huh? There's a couple of margins that I want to check. So there's a caval margin. Yeah. The inferior margin seemed like miles away. Yeah, so I think this is - this is going to be the superior caval margin here, which seems quite free, and then this is the left renal margin, which also seems free although it may be a little bit closer. So this just got a little disrupted here, or...? Well - well, this is - this is the - this is the left... Oh, that's actually the vessel. This is the left renal vein orifice here, so tumor is actually going into the left renal. Wow, that's - that is gorgeous and terrible for the patient. Yeah, and so, you know, I'd love to check that margin. Yeah. Yeah. I think that's the one I'm most worried about. Okay. And we certainly could take more if we need to there, but... Well, we're happy to take off whatever you want, so you want to just do the vein to start? Do you want to take the IVC margin? Might as well do the IVC margin all s - now, but that's - that's pretty - that's pretty far away all around. I mean, I'd be pretty surprised, but... Yeah, sure - you never know - might as well - I guess, right? Yep. I'll check that. So let me do the vein first. I'll get that going, and then we'll go from there. And then - although maybe - maybe you - you could take a photograph before you did that if you don't mind. Sure, I'd love to do that. So I'm just going to try to prop it up with this clay so that you can nicely see Dr. Haynes' margins. Of course, it's a little slippery and doesn't really want to stay, so it just takes a second. Just check that the photo came out okay. Looks pretty good. I can see the renal margin. Let me see. The renal margin's a little bright, but it's probably about as good as we're going to get propped up. Alex, here's what I took. See if this is good enough for you. So we've got - here's the margins from above. Yeah, yeah, beautiful. And then we have the back and front. Yeah. Beautiful. That's great. What we're looking for here is - we're looking at the - the vein margins. You see, the tumor sort of bulges through the vein orifice, but that's not a positive margin because the tumor is actually - the margin is this. It's not this. And so we want to look at the edge of the vein to see if that's involved, and you can tell - by feeling it, it feels unlikely that it - to be involved because there's a nice lip there - but again, it's always go to take a look and figure out - especially in this case where there's plenty of room to take more. Sometimes, we've had where we've taken them up off of the - you know, the IVC basically at the pericardium, and even if the margin is positive, we're not going to take more, but... Now presumably, we don't need a frozen of the sarcoma, right? No, diagnosed - it's already been diagnosed, so... So part of the reason why I come here for this is is that we can have a discussion about what we're looking for. Additionally, orientation isn't always straightforward. It's extremely helpful when they come in. When surgeons come in and help us orient - especially complex ones like this. There's a little branch, huh? Yeah, there's a lot of little branches there. Those are the short hepatics. You know, basically, what we do is we're both available, and we get everything all set. And then, like I did today, ideally free up everything other than the vascular attachments, and then we'll clamp and cut. And it actually works out perfectly because it's just about the right amount of time while I'm here reviewing the specimen for them to reconstruct the cava. So it's kind of like on the fly if you guys are rotating immediately, everything you're doing. Yeah. Yeah. So I just have to cut the sutures off because... Yeah, of course. One blade. It can sometimes be challenging to, you know, coordinate the operating day because we both have to be available and have to be flexible enough to - to do that. I usually block off, you know, all or most of the day for something like this. Then Dr. Vagefi - when he joins me, usually he'll do some small cases in the morning, and then - so he's ready for when I need him, which is - today was relatively quick. It's often not until later in the afternoon when the tumor's out - depends a little on whether we're taking other organs or other things out along with it. So what does he do when you're doing one of these cases? Dr. Vagefi. So he reconstructs the cava. That makes sense. He does a lot of that when he takes out livers. Exactly right. And, you know - suppose we could have someone from vascular helping as well, but a lot of these cases - if we - you know, particularly if we're going up, you know, putting our clamp suprahepatic or retrohepatic, having someone who spends a lot of time with the liver is good. Also, he does a lot of kidney reimplantation and the like, so - you know, the... Yeah, he does all this kind of stuff. So he has to reimplant the left renal vein into the graft. Who better do that than the transplant surgeon? Yeah, exactly. Two margins here. This is the renal vein. This is the IVC. I had to sort of fold it over a little bit just to get it all on. But you can see we have essentially a cross-section of the vessel here. And then we'll throw them on and have a look. The attending is coming. I am a lowly resident, so I will do what I can here. Pretty good here, huh? There he is. He wanted us to take a look at the vascular margins - both of which, proximally, look really quite free. This is the left renal vein and the other... Correct. The kidney that's still in her body. So how was this margin taken then? So I - what I did was - if this was the tube, I snipped sideways like this and then went all the way around, and I put the ring margin up - straight down, so... Painted? No, not painted. It's just true margin up. Same thing with the IVC, I snipped in from the side, went all the way around. That's - this is okay. This all looks clear. That's perfectly fine. This is just the area of concern here. Yeah, because the tumor seems to be - come from the posterior aspect of everything. Okay, yeah, because it looks like this anterior wall is all there. Correct. But you've already taken some. Did you... Yeah, sorry, it's actually frozen sitting on the microscope right now. Okay. And then I - I wonder should we - should we - this is - it's interesting. I mean, it's a little thicker than the vein wall usually is. It's far away from the tumor, but... Do you have a probe? There's lumen. It's probably like an obstruction. Maybe, yeah. I mean, it was - it was pretty obstructed and had big collaterals. Alright, let's take a look at this. Alright, well it looks like normal vessel wall. I don't see any sarcoma here. Typically we - we look at the margins for sarcoma because we want to make sure that we don't need to take anymore. And I like to look at the margins myself with the pathologist. Here we have expert sarcoma pathologists like Dr. Chebib, who - all he does is look at sarcomas, because sometimes a diagnosis can be unclear. We want to know whether or not we need to take more tissue, but also sometimes, we use the option of intraoperative radiation therapy. We use that - make that decision based on the margins and the appearance under the microscope. For this patient, she's on a protocol that uses proton radiation where we've already given her essentially a boost to her high-risk margins, so we wouldn't use intraoperative radiation for her in any case. But for other - other patients with similar tumors, we do sometimes use intraoperative radiation therapy. We can actually deliver focused radiation to margins at risk while the patient's asleep and open in the operating room. Let him know that the margins are clear and make sure that they're happy.