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Nephrectomy with caval thrombectomy

Incision – open; transverse, chevron or Makuuchi

Initial steps:

  • Mobilisation of colon (+/- duodenum), exposure of gonadal/IVC and hilar dissection
  • Sling renal vein
  • Early control of renal artery – may allow retraction of thrombus, and reduces blood flow
  • Divide lateral and superior renal attachments and divide ureter
  • Expose cava and achieve ability for proximal and distal control

Level 1:

  • Milk thrombus back into renal vein after early arterial ligation
  • Vascular clamp on cava around renal vein ostium, avoiding complete caval occlusion but ensuring all thrombus contained
  • Sharp cold excision of renal vein ostium allowing en bloc nephrectomy with tumour thrombus
  • Closure of cavotomy with continuous 4-0 prolene

Level 2:

  • Early ligation of artery
  • If left side – control and ligate adrenal, gonadal +/- left lumbar veins
  • Expose IVC, ligate right gonadal on anterior surface
  • Clamp contralateral renal vein and infrarenal IVC before suprarenal IVC
  • L-shaped incision into cava, excising renal vein ostium, excising renal vein en bloc with tumour thrombus
  • Inspect caval lumen to ensure all thrombus removed
  • Closure ensuring flushing out of air and debris
  • Hinman (and Psutka) – release infrarenal clamp prior to tying knot, then contralateral then suprarenal
    • Some say – doesn’t really matter what order of clamp removal – main thing is to ensure ‘vent’ to flush out air/clot/debris before tying closed repair

Level 3:

  • Heterogenous group of patients
  • Short hepatics directly into IVC must be controlled/ligated
  • Often requires liver mobilisation using liver transplant techniques
    • Division of ligamentum teres then falciform ligament
    • Continue dissection to right side – taking down right superior coronary ligament
    • Then left side – division of left triangular ligament
    • Take down visceral peritoneum overlying right hepatic hilum and IVC, then divide right inferior coronary ligament and hepatorenal ligament
    • This opens the lesser sac allowing Pringle manoeuvre
  • Milk thrombus below hepatic venous confluence if possible to avoid need for Pringle and hepatic occlusion
  • 3 x hepatic veins – cannot be divided – significant venous return. Obstruction leads to Budd-Chiari syndrome.
  • Combination of IVC cross clamp, and Pringle, can result in haemodynamic instability due to insufficient venous return or blood loss from collaterals
    • Test clamp – if significant hypotension (MAP drops by 30 %), may need v-v bypass or cardiopulmonary bypass
    • Other complications of Pringle – hepatic ischaemia, portal vein thrombosis, splenic engorgement and rupture

 

If doing left nephrectomy – the right kidney will become congested and distended ++ during caval occlusion (no collateral venous drainage cf. left), so right renal artery and vein often clamped

Level 4:

  • Will need cardiovascular surgeons and cardiopulmonary bypass with hypothermic circulatory arrest (unless can be milked below diaphragm allowing v-v bypass)
  • Intra-abdominal technique with dissection of central tendon described

 

Other technical points – caval resection/replacement, 50 % narrowing, post-op warfarinisation, lymphadenectomy, complications

v-v bypass – shunting of blood from inferior IVC or femoral vein, and delivery back into central line or brachial vein. Lumbars and intercostals not bypassed.

Cardiopulmonary bypass – needed for cases where cannot clamp above, no need for Pringle, do not have to ligate or secure lumbars (although they may bleed once off bypass if damaged), allows complete inspection of dry IVC and hepatics, lower risk of embolisation and allows longer thrombectomy.

 

Auxiliary caval procedures:

  • If cava will be > 50 % of preoperative diameter, no significant intervention required
  • If < 50 %, may need patch cavoplasty to prevent IVC stenosis and thrombotic events
    • Bovine pericardium, autologous pericardium, PTFE, Dacron, Gore-tex
    • Similar principles to cavotomy – release infrarenal clamp and allow expulsion of air and clot before completing repair
  • If circumferential caval resection required or defect too large – caval replacement with PTFE graft
    • Post-operative anticoagulation required lifelong
  • If significantly bland thrombus below kidneys
    • IVC ligation with care to preserve collaterals
    • Intra-operative IVC filter

 

 

 

Peritoneal attachments of liver

  • Falciform ligament
    • From umbilicus behind linea alba towards xiphisternum
    • In its posterior free margin it contains the ligamentum teres, which is the obliterated left umbilical vein – this deviates to the right of midline to enter the fissure for ligamentum teres on the liver
    • Once the ligamentum teres is delivered to the liver, the falciform ligament continues up and right of midline between diaphragm and supero-anterior liver, where the two layers separate
  • The under surface of diaphragm reflects on to superior surface of liver on right lobe forming upper / anterior layer of coronary ligament
    • This then descends anteriorly over the liver, sweeps over inferior border, and as it comes back up posterior liver reflects over the right kidney and adrenal to form lower / posterior layer of coronary ligament attaching to diaphragm
  • The two layers of coronary ligament approximate at the right lateral end to form the right triangular ligament
  • Between the upper and lower coronary ligaments and right triangular ligament is the bare area, which is in contact with the IVC
  • The left triangular ligament also has two layers approximating – anterior layer from the falciform ligament which has extended anteriorly, and posterior layer continuous with the lesser omentum