Huang Qingbo, Zhao Guodong, Chen Yonghui, Wu Peng, Li Shuanglei, Peng Cheng, Liu Kan, Yu Hongkai, Gao Yubo, Xiao Cangsong, Fu Qiang, Shen Hao, Li Qiuyang, Li Nan, Wang Haiyi, Fam Xeng Inn, Wang Baojun, Liu Rong, Zhang Xu, Ma Xin
Faculty of Urology, Third Medical Center, Chinese PLA General Hospital, Beijing, China.
Faculty of Hepato-Pancreato-Biliary Surgery, First Medical Center, Chinese PLA General Hospital, Beijing, China.
J Urol. 2023 Jan;209(1):99-110. doi: 10.1097/JU.0000000000002952. Epub 2022 Oct 4.
We introduce an intrapericardial control technique using a robotic approach in the surgical treatment of renal tumor with level IV inferior vena cava thrombus to decrease the severe complications associated with cardiopulmonary bypass and deep hypothermic circulatory arrest.
Eight patients with level IV inferior vena cava thrombi not extending into the atrium underwent transabdominal-transdiaphragmatic robot-assisted inferior vena cava thrombectomy obviating cardiopulmonary bypass/deep hypothermic circulatory arrest (cardiopulmonary bypass-free group) by an expert team comprising urological, hepatobiliary, and cardiovascular surgeons. The central diaphragm tendon and pericardium were transabdominally dissected until the intrapericardial inferior vena cava were exposed and looped proximal to the cranial end of the thrombi under intraoperative ultrasound guidance. As controls, 14 patients who underwent robot-assisted inferior vena cava thrombectomy with cardiopulmonary bypass (cardiopulmonary bypass group) and 25 patients who underwent open thrombectomy with cardiopulmonary bypass/deep hypothermic circulatory arrest (cardiopulmonary bypass/deep hypothermic circulatory arrest group) were included. Clinicopathological, operative, and survival outcomes were retrospectively analyzed.
Eight robot-assisted inferior vena cava thrombectomies were successfully performed without cardiopulmonary bypass, with 1 open conversion. The median operation time and first porta hepatis occlusion time were shorter, and estimated blood loss was lower in the cardiopulmonary bypass-free group as compared to the cardiopulmonary bypass group (540 vs 586.5 minutes, 16.5 vs 38.5. minutes, and 2,050 vs 3,500 mL, respectively). Severe complications (level IV-V) were also lower in the cardiopulmonary bypass-free group than in cardiopulmonary bypass and cardiopulmonary bypass/deep hypothermic circulatory arrest groups (25% vs 50% vs 40%). Oncologic outcomes were comparable among the 3 groups in short-term follow-up.
Pure transabdominal-transdiaphragmatic robot-assisted inferior vena cava thrombectomy without cardiopulmonary bypass/deep hypothermic circulatory arrest represents as an alternative minimally invasive approach for selected level IV inferior vena cava thrombi.
我们介绍一种在心包内控制技术，采用机器人手术方法治疗伴有IV级下腔静脉血栓的肾肿瘤，以减少与体外循环和深低温停循环相关的严重并发症。
8例IV级下腔静脉血栓未延伸至心房的患者，由泌尿外科、肝胆外科和心血管外科专家团队实施经腹-经膈肌机器人辅助下腔静脉血栓切除术，避免体外循环/深低温停循环（非体外循环组）。经腹解剖中心膈肌腱和心包，直至暴露心包内下腔静脉，并在术中超声引导下在血栓头端近端套扎。作为对照，纳入14例行机器人辅助下腔静脉血栓切除术并使用体外循环的患者（体外循环组）和25例行开放血栓切除术并使用体外循环/深低温停循环的患者（体外循环/深低温停循环组）。对临床病理、手术和生存结果进行回顾性分析。
成功实施8例机器人辅助下腔静脉血栓切除术，无需体外循环，1例中转开放手术。与体外循环组相比，非体外循环组的中位手术时间和首次肝门阻断时间更短，估计失血量更低（分别为540分钟对586.5分钟、16.5分钟对38.5分钟、2050毫升对3500毫升）。非体外循环组的严重并发症（IV - V级）也低于体外循环组和体外循环/深低温停循环组（25%对50%对40%）。在短期随访中，三组的肿瘤学结果相当。
单纯经腹-经膈肌机器人辅助下腔静脉血栓切除术，无需体外循环/深低温停循环，是治疗特定IV级下腔静脉血栓的一种替代性微创方法。
