Transdiaphragmatic approach to intrapericardial inferior vena cava for intrahepatic thrombectomy: first experience

Radical excision of renal cancer with propagation into intrahepatic and intrapericardial inferior vena cava (IVC) has become an accepted surgical approach. We have verified first on the cadaver and then on two patients the possibility to approach the intrapericardial IVC through a limited diaphragmatic incision. Operating field is exposed through a transverse abdominal ap-proach combined with an epigastric vertical incision. After kidney mobilization and renal artery division, the kidney is attached only to the inferior vena cava. After ligaments dissection the liver is rotated downward giving excellent exposure to the IVC. The diaphragm is exposed and incisioned in the midline at the level of its anterior insertion to the central tendon. The pericardium is entered. Thrombus extremity is localized and a tape is placed above it around the IVC. Umbilical tapes are passed around the hepatic hilum, the infrarenal IVC and the controlateral renal vessels. Then they are clamped with a Tourniquet. The infrahepatic, intrahepatic and suprahepatic portions of the IVC are well exposed and the thrombus can be safely removed. Median sternotomy combined with a midline abdominal incision is the standard procedure for removal of intrahepatic and intrapericardial thrombi. This extended thoraco-abdominal incision is time-consuming and invasive. Transverse abdominal approach combined with an epigastric vertical incision in the midline is well tolerated by the patients. Though liver mobilization is easily achieved after ligaments are dissected, sovrahepatic IVC is hardly controlled due to either its shortness and presence of sovrahepatic veins. We have verified the possibility to approach the intrapericardial IVC through a limited diaphragmatic incision. Tourniquets are placed around the intrapericardial and infrarenal tract of the IVC. Pringle manoeuvre is used to control the blood flow into the liver. Total vascular exclusion of the infrahepatic vena cava is achieved thanks to the contemporaneous clamping of the contralateral renal vein. Approaching pericardium through this short incision yields notable advantages: a less invasive procedure, being sternotomy avoided; a simple control of upper extension of the thrombus avoiding the difficult dissection of the IVC between the liver and diaphragm and the liver derotation; a decreased blood loss, due to the complete absence of circulation in the intrahepatic IVC making extracorporeal by-pass unnecessary. Thrombus extension above the sovrahepatic veins abates indication to this kind of surgical approach.