Retroperitoneal laparoscopic radical nephrectomy for renal cell carcinoma with infrahepatic vena caval thrombus.

Purpose: The retroperitoneal laparoscopic approach is utilized to treat a right renal tumor with vena caval thrombus reaching infrahepatic veins.

Materials And Methods: The patient is an 87-year-old woman with a tumor measuring 8 x 9 cm and a vena caval thrombus (7 cm), stretching as far as the subhepatic vein. The retroperitoneal laparoscopic approach is used with the patient in the lateral position and the usual 4 laparoscopy trocars. A wide incision is made through Gerota's fascia, the renal artery clipped and severed, and the vena cava is dissected to the level of the infrahepatic veins; a vessel loop is encircled twice upstream of the thrombus. Vessel loop is similarly tied below the thrombus. An 8 cm abdominal wall incision is made joining two trocars on the medial and anterior axillary side. After retrieving the vessel loops and closing the vena cava by pulling gently on the loops, thrombus is extracted through a cavotomy under direct vision, with removal of the surgical specimen, positioning of the Satinsky haemostatic forceps, and closure of the vena cava using uninterrupted Prolene 2/0 sutures.

Results: Blood loss was 300 cc. The patient was discharged on day 6, and a CT-scan 4 months later disclosed no signs of recurrence.

Conclusions: This is an original solution that opens the way to further indications for using retroperitoneal laparoscopy to treat tumors extending into the inferior vena cava.