Hepatobiliary and Retroperitoneal Sarcoma Division, Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, India.
Ann Surg Oncol. 2024 Aug;31(8):5431-5432. doi: 10.1245/s10434-024-15254-4. Epub 2024 Apr 18.
Radical resection remains the only potential cure in the management of inferior vena cava (IVC) leiomyosarcomas with multivisceral resections often needed (Borghi et al. in J Cardiovasc Surg (Torino) 63:649-663, 2022). This video describes the technical nuances of surgical resection of a large retrohepatic IVC leiomyosarcoma.
Computed tomography of a 60-year-old woman revealed a 12 × 12 × 9.5 cm mass in the right suprarenal region infiltrating the IVC with intraluminal extension up to the hepatic venous confluence. The mass involved the right hepatic vein with infiltration of segment 7 of the liver and splaying of the right portal vein. Robust lumbar venous drainage from the infratumoral IVC was seen. En bloc IVC resection without reconstruction along with a right hepatectomy and right nephrectomy was performed via a right thoracoabdominal approach.
After a Catell-Braasch maneuver, the surgery can be broadly divided into four major steps: (1) Right retroperitoneal mobilization of the tumor and right kidney with infratumoral IVC control, (2) mobilization of the right liver with suprahepatic IVC control, (3) division of the right portal structures with right hepatectomy, and (4) en bloc resection of the IVC tumor. Reconstruction of the IVC was not performed owing to the presence of venous collaterals (Langenbecks et al. in Arch Surg 407:1209-1216, 2022). Final histopathology showed a high-grade leiomyosarcoma with histologic organ invasion in the liver and right kidney with resected margins free of the tumor (R0).
Meticulous preoperative planning and expertise in liver resection and retroperitoneal surgeries facilitates such radical yet safe multivisceral resection for a large retrohepatic IVC leiomyosarcoma without the need for a cardiopulmonary bypass.
根治性切除术仍然是治疗下腔静脉（IVC）平滑肌肉瘤的唯一潜在方法，通常需要进行多脏器切除术（Borghi 等人在 J Cardiovasc Surg（Torino）63:649-663, 2022 中描述）。本视频介绍了肝后大型 IVC 平滑肌肉瘤切除术的技术要点。
对一名 60 岁女性的计算机断层扫描显示，右侧肾上腺区域有一个 12×12×9.5 厘米的肿块，浸润 IVC，腔内延伸至肝静脉汇合处。该肿块累及右肝静脉，浸润肝 7 段并使右门静脉分叉。可见从肿瘤下方 IVC 到下腔静脉的强大腰静脉引流。通过右胸腹联合入路进行了无重建的整块 IVC 切除，同时进行右肝切除术和右肾切除术。
在进行 Catell-Braasch 操作后，手术可大致分为四个主要步骤：（1）右后腹膜肿瘤和右肾及下腔静脉的游离；（2）肝上腔静脉控制下的右肝游离；（3）右门静脉结构的分离和右肝切除术；（4）IVC 肿瘤的整块切除。由于存在静脉侧支（Langenbecks 等人在 Arch Surg 407:1209-1216, 2022 中描述），未进行 IVC 重建。最终组织病理学显示为高级别平滑肌肉肉瘤，肝和右肾有组织器官侵犯，切缘无肿瘤（R0）。
术前精心规划和肝脏切除术及腹膜后手术专业知识有助于对大型肝后 IVC 平滑肌肉瘤进行这种激进但安全的多脏器切除术，而无需体外循环。
