RU2822075C1 - Method of laparoscopic radical nephrectomy with thrombectomy from inferior vena cava - Google Patents

Abstract

FIELD: medicine; oncourology; abdominal surgery.

SUBSTANCE: renal artery, a kidney within Gerota fascia is separated by the first stage. Renal artery is clipped and cut off. At the next stage, the inferior vena cava is separated below the renal vessels, then the inferior vena cava is separated up to the level of short hepatic veins. Above the level of renal vein discharge, at the level of short hepatic veins, the inferior vena cava is allocated in a circular manner. At this point of the inferior vena cava, a vascular tourniquet with length of 70 cm is inserted under the inferior vena cava, and both ends of the tourniquet are brought out through an additional port for laparoscopic surgery under the xiphoid process. Thus, it is possible to temporarily clamp the inferior vena cava by tightening and fixing the tourniquet through the installed silicone tube. With this method, the blood flow in the inferior vena cava is temporarily closed from the external medium without using vascular clamps.

EFFECT: method enables avoiding the vascular clamp in the area of short hepatic veins, eliminating the risk of intraoperative damage to the inferior vena cava during the manipulation; to perform temporary occlusion of the inferior vena cava at any moment of the operation even without visual control of the operating picture, and also significantly increases the safety of this stage of the surgical intervention.

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Description

The method of laparoscopic radical nephrectomy with thrombectomy from the inferior vena cava is an invention related to the medical discipline in the field of urology and abdominal surgery, and can be used in the surgical treatment of renal cell cancer complicated by tumor thrombosis in the inferior vena cava (IVC).

A known method of laparoscopic nephrectomy with thrombectomy from the IVC by installing trocars, forming a carboxyperitoneum, mobilizing the kidney to be removed, isolating and crossing the gonadal vein from the side of the kidney to be removed and crossing the ureter from the side of the kidney to be removed, isolating the anterior wall of the IVC, isolating and crossing the renal pedicle of the underlying removal of the kidney, cutting off the kidney to be removed, mobilization of the left lobe of the liver, mobilization of the renal vein of a healthy kidney, mobilization of the IVC, transection of the lumbar veins, clamping of the tributaries of the IVC, cavatomy, thromboextraction with resection of a section of the IVC wall, suturing of the IVC defect, starting blood flow into the IVC and removal of the severed kidney and tumor thrombus with a section of the resected IVC wall (Romero F.R., Muntener M., Bagga H.S., Brito F.A., Sulman A., Jarrett T. Pure Laparoscopic radical nephrectomy with level II vena caval thrombectomy. Urology. 2006; 68(5): 1112 -1114).

There is a known method of laparoscopic robot-assisted radical nephrectomy with thrombectomy from the IVC by installing trocars, forming a carboxyperitaneum, mobilizing the kidney to be removed, isolating and crossing the gonadal vein from the side of the kidney to be removed and crossing the ureter from the side of the kidney to be removed, mobilizing the triangular and coronary ligament of the liver, mobilization of the right and left lobes of the liver, isolation of the anterior wall of the IVC, isolation and intersection of the renal pedicle, cutting off the kidney to be removed, isolation of the hepatic veins and their clipping, mobilization of the renal vein of a healthy kidney, mobilization of the IVC, intersection of the lumbar veins, clamping of the tributaries of the IVC, kavatomy , thromboextraction with resection of a section of the IVC wall, suturing the IVC defect, starting blood flow into the IVC and removing the severed kidney and tumor thrombus with a section of the resected IVC wall (Wang B., Li H., Huang Q., Liu K., Fan Y., Peng Ch., Gu L., Li X., Guo G., Liu R., Hu M., Zhao G., Wang H., Liu F., Xiong J., Zhang X., Ma X. Robot-assisted Retrohepatic Inferior Vena Cava Thrombectomy: First or Second Porta Hepatis as an Important Boundary Landmark. European urology. 2018).

There is a known method of laparoscopic radical nephrectomy with thrombectomy from the IVC by installing trocars, forming a carboxyperitoneum, mobilizing the kidney to be removed, isolating and crossing the gonadal vein from the side of the kidney to be removed and crossing the ureter from the side of the kidney to be removed, isolating the anterior wall of the IVC, isolating and crossing the renal pedicle kidney to be removed, cutting off the kidney to be removed, mobilization of the renal vein of a healthy kidney, mobilization of the IVC, intersection of the lumbar veins, clamping of the tributaries of the IVC, cavatomy, thromboextraction with resection of a section of the IVC wall, suturing the IVC defect, starting blood flow into the IVC and removing the severed kidney and tumor thrombus with area of the resected IVC wall (Perlin D.V., Zipunnikov V.P. Dymkov I.N., Shmanev A.O., Popova M.B. Laparoscopic thrombectomy from the inferior vena cava with radical nephrectomy for locally advanced renal cell carcinoma Journal of Urology 2016; 4: 5-14).

There is a known method of laparoscopic radical nephrectomy with thrombectomy from the IVC by, before installing the trocars required for laparoscopic surgery, under X-ray control necessary to visualize the progress of the thromboextractor, an endovascular installation (installation through the great vessels of the body) is carried out in the IVC of an unopened thromboextractor, and the thromboextractor is opened at the apex of the tumor thrombus, after the nephrectomy stage. After installing an unopened thromboextractor, trocars are installed, carboxyperitoneum is formed, the kidney to be removed is mobilized, the ureter is crossed from the side of the kidney to be removed, the anterior wall of the IVC is isolated, the renal pedicle of the kidney is isolated and crossed, the kidney to be removed is cut off, the renal vein of the healthy kidney is mobilized, mobilization IVC, intersection of the lumbar veins, clamping of the tributaries of the IVC, cavatomy, thromboextraction using a previously installed thromboextractor, suturing the IVC defect, starting blood flow into the IVC and removing the severed kidney and tumor thrombus with a section of the resected wall of the IVC (Patent RU 2682597 C1 METHOD OF LAPAROSCOPIC RAD ICAL NEPHRECTOMY WITH THROMBECTOMY FROM THE INNER VENA CAVA Gallyamov E.A., Biktimirov R.G., Agapov M.A., Sergeev V.P., etc.).

The disadvantages of all known methods are the following aspects:

- dependence on the presence of vascular clamps to block the inferior vena cava;

- at the stage of resection of the inferior vena cava, a pile-up of vascular clamps occurs in the area of surgical interest, which is accompanied by inconvenience when performing cavatomy, thromboextraction and suturing of the inferior vena cava;

- if bleeding occurs from the main vessel, it becomes impossible to clamp the inferior vena cava due to reduced visualization, which can lead to fatal consequences;

- there is a risk of damage to the intima of the inferior vena cava when using vascular clamps;

- there is a risk of damage to the inferior vena cava at the time of applying the vascular clamp itself, since more than 50% of all damage to the IVC occurs during the use of the vascular clamp.

Disclosure of the Invention

The technical problem of the invention is to develop a method of laparoscopic radical nephrectomy with thrombectomy from the IVC, devoid of these disadvantages.

The technical result of the invention is aimed at increasing the safety of the method of laparoscopic radical nephrectomy with thrombectomy from the IVC by reducing the risks of intraoperative and postoperative complications.

In the developed method, achieving the specified result is due to the following:

- refusal of vascular clamp in the area of the short veins of the liver eliminates the risk of intraoperative damage to the IVC during manipulation;

- the use of the described nephrectomy technique with resection of the IVC makes it possible to cause temporary occlusion of the inferior vena cava at any time during the operation, even without visual control of the surgical picture. Occlusion of the IVC is caused by the external environment, which significantly increases the safety of this stage of surgical intervention;

- when performing thromboextraction of large tumor thrombi that extend above the short veins of the liver, it is possible to clamp the inferior vena cava around the tumor thrombus. At the stage of thromboextraction, it is necessary to slightly relax the vascular tourniquet, which will allow thromboextraction to be performed. After completion of thromboextraction, it is necessary to completely block the IVC and perform the reconstructive stage of the surgical procedure to the extent of suturing the inferior vena cava.

Thus, as a result of the observations, it was revealed that the new technique of laparoscopic nephrectomy with resection of the IVC makes it possible to conveniently and safely perform surgical interventions of this level without the use of other complex manipulations. The vascular tourniquet optimally allows you to block the lumen of the IVC proximal to the tumor thrombus.

Thus, the original features of the operation are:

- before cavatomy, it is necessary to pass a vascular tourniquet 70 cm long circularly under the IVC in the area of the short hepatic veins and remove it through a separate port for laparoscopic surgery under the xiphoid processes. The vascular tourniquet is passed through a 30 cm long silicone tube using cystoscopy forceps. By pulling and fixing the tourniquet, temporary occlusion of the IVC occurs.

When conducting a patent search, no works were found that provided a method for temporary occlusion of the inferior vena cava from the external environment when performing laparoscopic nephrectomy with resection of the inferior vena cava for a tumor thrombus.

The above stages of the operation are necessary in order to increase the convenience of working with the great vessels during laparoscopic access, thereby increasing the safety of using laparoscopic access for resection of the great vessels.

Clinical example

Patient A., 56 years old, was admitted to the clinic as part of a planned hospitalization. According to MSCT, right kidney cancer cT3bV2N0M0 was diagnosed with the presence of a tumor thrombus 4-5 cm above the renal veins. The patient was prepared for surgical treatment. An operation was performed - laparoscopic radical nephrectomy with resection of the IVC for tumor thrombosis.

Under endotracheal anesthesia, after processing the surgical field, a carboxyperitoneum of up to 12 mm was applied. Hg, 3 laparoscopic working trocars were installed, the parietal peritoneum was dissected along the Told line and the colon and duodenum were mobilized. Then the right kidney to be removed was mobilized. The lower pole of the kidney is mobilized at the level of the psoas muscle. The intersection of the gonadal vein and the right ureter was performed. The right kidney within the Gerota's fascia is completely mobilized to the vascular pedicle using the LigaSure bipolar coagulator.

The vascular pedicle is represented by 1 renal artery and 1 renal vein. A tumor thrombus is visualized in the renal vein, extending into the inferior vena cava. The renal artery passing under the renal vein was isolated and clipped twice, and then transected.

The next step is to isolate the inferior vena cava (IVC). At the level of the lower pole of the right kidney, the IVC is circularly isolated and taken onto a vascular tourniquet. The left renal vein is isolated circularly and also taken on a tourniquet.

The next step is to mobilize the IVC (position 1 in Figures 1, 2, 3) above the level of the renal veins, and visualize the tip of the tumor thrombus. Above the level of the tumor thrombus, a vascular tourniquet made of textile 70 cm long was placed circularly (position 3 in Figures 1, 2, 3). This tourniquet is brought out through an additionally installed laparoscopic port under the xiphoid process.

Using cystoscopy forceps, this textile tourniquet is passed along a silicone tube (position 2 in Figures 1, 2, 3) 30 cm long (Figure No. 1).

The next step is to clamp the inferior vena cava below the renal vessels using a vascular clamp. The left renal vein was clamped with a vascular clamp. In the subhepatic space, through moderate traction of the tourniquet inside the silicone tube, complete occlusion of the inferior vena cava was performed (Figure No. 2).

Cavatomy was performed using cold scissors. Extraction of the tumor thrombus was performed (position 4 in Figure No. 3). The inferior vena cava is sutured with 3-0 prolene thread in a single row. The vascular clamps are removed, the vascular tourniquet is relaxed. The IVC occlusion time was 12 minutes. Bleeding at this stage is about 100 ml.

Further mobilization of the right kidney was performed. The right kidney in a single block with a tumor thrombus and a section of the inferior vena cava was placed in an endobag. After which an incision was made in the groin area on the right and the macroscopic specimen was removed.

Layer-by-layer suturing of the wound was performed. Drainage of the abdominal cavity.

On the first day after surgery, the patient was transferred from intensive care to the general ward. On day 6, the patient was discharged from the hospital in satisfactory condition. There were no further postoperative complications in the patient.

A total of 4 surgical interventions were performed using the proposed method. In no case were intraoperative or postoperative severe complications observed.

The proposed method significantly increases the safety of laparoscopic radical thrombectomy from the IVC by reducing the risks of intraoperative and postoperative complications.

Claims (1)

A method of laparoscopic nephrectomy with thromectomy from the inferior vena cava for kidney cancer, including installation of trocars, mobilization of the kidney to be removed, treatment of the ureter, isolation of the inferior vena cava with installation of a vascular clamp, isolation of the left renal vein with installation of a vascular clamp, isolation of the inferior vena cava above the renal vessels in the subhepatic space, holding a circular tourniquet 70 cm long, removing the tourniquet inside the silicone tube through an additionally installed trocar under the xiphoid process, temporary occlusion of the inferior vena cava is achieved by pulling and fixing the tourniquet in the silicone tube, then kavatomy, thrombectomy, suturing of the inferior vena cava are performed, removing vascular clamps, loosening the vascular tourniquet, placing the removed kidney with a tumor thrombus in an endobag and removing it through an additional incision in the groin area.