Department of Urology, Chinese PLA General Hospital, Beijing, China.
Department of Second Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, China.
Eur Urol. 2018 Oct;74(4):512-520. doi: 10.1016/j.eururo.2017.11.017. Epub 2017 Dec 7.
Robot-assisted retrohepatic inferior vena cava (IVC) thrombectomy (RA-R-IVCTE) has been reported only for limited series.
To describe in detail the techniques for RA-R-IVCTE with regard to the relationship of a proximal thrombus to either the first porta hepatis (FPH) or second porta hepatis (SPH).
DESIGN, SETTING, AND PARTICIPANTS: From May 2013 to July 2016, 22 patients with R-IVC tumor thrombi were admitted to our hospital.
RA-R-IVCTE was performed using the Rummel tourniquet technique. For a proximal thrombus inferior to the FPH, we ligated some short hepatic veins (SHVs; typically 1-3). For a thrombus between the FPH and SPH, we mobilized the right lobe of the liver from the IVC by ligating additional SHVs. For a thrombus near or above the SPH but below the diaphragm, we mobilized both the right and left lobes of the liver to obtain high proximal control of the suprahepatic and infradiaphragmatic IVC, and simultaneously clamped the FPH.
Detailed techniques were described for various scenarios and perioperative outcomes were recorded.
The median operation time was 285min (interquartile range [IQR] 191-390). Intraoperative estimated blood loss was 1350ml (IQR 1000-2075ml). Some 63.6% of patients required an intraoperative blood transfusion and 68% were transferred to the intensive care unit after surgery. Grade IV complications developed in five cases. Vascular injuries (4 cases) were treated with intraoperative endoscopic sutures. An intestinal fistula was found on postoperative day 7 in one case; treatment with gastrointestinal decompression and drainage resolved the condition by 1 mo.
Even though the risks involved are high, RA-R-IVCTE is feasible for selected patients. The FPH/SPH is an important boundary landmark for RA-R-IVCTE. The location of proximal IVC tumor thrombi in relation to the FPH or SPH should determine the technique used.
Robot-assisted thrombectomy for retrohepatic inferior vena cava tumor thrombus is feasible in selected patients.
机器人辅助肝后下腔静脉（IVC）血栓切除术（RA-R-IVCTE）仅在有限的系列中报告过。
详细描述 RA-R-IVCTE 的技术，涉及近端血栓与第一肝门（FPH）或第二肝门（SPH）的关系。
设计、设置和参与者：2013 年 5 月至 2016 年 7 月，我院收治 22 例肝后 IVC 肿瘤血栓患者。
使用 Rummel 止血带技术进行 RA-R-IVCTE。对于位于 FPH 以下的近端血栓，我们结扎一些短肝静脉（SHV；通常为 1-3 条）。对于位于 FPH 和 SPH 之间的血栓，我们通过结扎额外的 SHV 从 IVC 中移动右叶肝脏。对于靠近或位于 SPH 以上但低于膈肌的血栓，我们同时移动右叶和左叶肝脏，以获得肝上和膈下 IVC 的高近端控制，并同时夹住 FPH。
详细描述了各种情况下的技术，并记录了围手术期结果。
中位手术时间为 285 分钟（四分位距 [IQR] 191-390）。术中估计失血量为 1350ml（IQR 1000-2075ml）。约 63.6%的患者需要术中输血，68%的患者术后转入重症监护病房。5 例发生 4 级并发症。4 例患者采用术中内镜缝合治疗血管损伤。1 例术后第 7 天发现肠瘘；通过胃肠减压和引流，1 个月后治愈。
即使涉及的风险很高，RA-R-IVCTE 对选定的患者来说也是可行的。FPH/SPH 是 RA-R-IVCTE 的重要边界标志。近端 IVC 肿瘤血栓相对于 FPH 或 SPH 的位置应决定使用的技术。
机器人辅助肝后下腔静脉肿瘤血栓切除术在选定的患者中是可行的。
