Robot-assisted laparoscopic retroperitoneal leiomyosarcoma resection with inferior vena cava graft replacement: a case report

Abstract

The aim of the present study was to report the initial clinical experience of robot-assisted laparoscopic retroperitoneal leiomyosarcoma resection with inferior vena cava graft replacement. The patient was a 45-year-old female with abdominal pain. She was referred to our hospital and found to be with a retroperitoneal mass (46 mm × 45 mm). The inferior vena cava and the distal part of left renal vein were invaded by the tumor and compression was obviously seen from magnetic resonance imaging. The serum level of potassium, epinephrine, norepinephrine, cortisol, adrenocorticotropic hormone and renin angiotensin aldosterone system were all in normal ranges before the surgery. The operation was performed via a six port, robot assisted, transperitoneal laparoscopic approach. The tumor was completely resected and adherent part of inferior vena cava (approximately 5 cm) was dissected. Considering severe impairment of the great vessel, we decided to replace excised caval segment with an extended polytetrafluoroethylene graft and undertook the inferior vena cava reconstruction. The patient was discharged 11 days postoperatively with embolus in the graft. Anticoagulants were routinely administrated and the thrombus seemed to be smaller 3 months after operation. Abdominal pain was resolved and pathological examination finally confirmed that the tumor was leiomyosarcoma with negative margins free from tumor. Leiomyosarcoma of inferior vena cava present a technical challenge to surgeons. Comprehensive preparation should be made preoperatively to facilitate tumor resection and vascular management. In specific cases, robotic resection of leiomyosarcoma from great vessels and vascular repairment might be feasible options in experienced hands.

Keywords: Robot; inferior vena cava; reconstruction.

Figure 1

The tumor was assessed by imaging study. (A) CT scan indicated the tumor was near right adrenal gland and IVC. (B) MRI showed occlusion of inferior vena cava (left arrow) and local compression of left renal vein (right arrow). (C) An enhanced MRI was performed again to assess the tumor size (broad arrow) and tumor invasion of IVC (slim arrow) and left renal vein (short arrow). (D) Ultrasound indicated tumor invasion of IVC and local left renal vein. (E) Three-dimensional reconstruction of MRI image explicitly revealed tumor position (green) between veins (blue) and arteries (red) from the posterior direction. CT, computed tomography; MRI, magnetic resonance imaging; IVC, inferior vena cava.

Figure 2

Trocar placement for the surgery. A six-trocar technique was applied for the surgery. One 12 mm trocar near the umbilicus was the designated camera port (point C). Camera port, robot arm port 1 (near the liver margin) and 2 (above the anterior superior iliac spine) formed approximate 120 angular degree. Assistant port A1and A2 were 8cm from the camera port. A 5 mm trocar under the liver margin near the midclavicular line was used as the assistant port for liver retraction (point A3).

Figure 3

Surgical procedures of the operation. (A) Dissection of adipose tissues and exposure of the mass. (B) Ligation of cephalic IVC, caudal IVC, RRV and LRV. (C) Dissection of tumor from IVC. (D) Jointing of RRV free end to the interposition graft. (E) Isolation of LRV by Hem-o-lok clips. (F) Prevention of the synthetic graft from bowels. IVC, inferior vena cava; RRV, right renal vein; LRV, left renal vein.

Figure 4

Outcomes of postoperative examination. (A) The ultrasound indicated a 45 mm filling defection in the upper synthetic graft. (B) The blood flow velocity of renal artery was 78 cm/s (left) and 81.9 cm/s (right) respectively 6 days postoperatively. (C) Three-dimensional reconstruction of MRI revealed that the graft was partially be occluded by thrombus one week postoperatively. (D) The continuity of right renal artery imaging was interrupted (arrow) one week postoperatively. (E) The pathological examination confirmed that the tumor was retroperitoneal leiomyosarcoma with negative margins R0 (under 100× magnification). (F) Embolus (arrow) in the graft seemed to be smaller 3 months after operation. MRI: magnetic resonance imaging.