Robotic Vena Cavoscopy: Real time assessment of tumor invasion
Anthony H. Chau, M.D., Erik P. Castle, M.D., Richard J. Fowl, M.D..
Mayo Clinic Arizona, Phoenix, AZ, USA.
OBJECTIVES: There is limited experience in robotic vascular surgery. We present a case demonstrating the feasibility and effectiveness of robotic vena caval surgery and vena cavoscopy.
METHODS: A 29 year old man with a history of metastatic testicular germ cell tumor and radical orchiectomy was referred to our tertiary center for a new retroperitoneal metastatic tumor encasing the aorta and inferior vena cava. After four cycles of chemotherapy, there was interval improvement in the tumor size. Given the patients young age, surgical resection was recommended for the opportunity for cure.
RESULTS: After induction of general anesthesia, the patient was placed in a modified lithotomy position. Six robotic ports were inserted in the bilateral lower abdomen. He was placed in steep Trendelenburg. The robotic surgical system was docked and connected to the ports. The small bowel and mesentery were mobilized. Proximal and distal control of the infra-renal aorta and inferior vena cava (IVC) was obtained with vessel loops. The retroperitoneal tumor was dissected off of the aorta but remained adherent to the IVC. To assess the extent of tumor invasion into the IVC, a small cavotomy was made and a flexible cystoscope was inserted into the vena cava. Intra-caval synechiae and thrombus were present but no tumor invasion was appreciated. The tumor was excised from the IVC. The intra-caval synechiae and thrombus were excised and sent for pathologic examination. Primary repair of the IVC was performed with 4-0 prolene suture. Further para-aortic lymphadenectomy was performed. Operative time was 383 minutes. Estimated blood loss was 150 ml. The patient was discharged on post-operative day 1. On pathologic examination, the retroperitoneal tissue demonstrated necrotic tumor. The intra-caval specimen was fibrous tissue with lipid-laden and hemosiderin-laden histiocytes.
CONCLUSIONS: Robotic vena caval surgery is a safe and effective minimally invasive alternative to open surgery. Vena cavoscopy can be utilized for real time assessment of tumor invasion and help determine the type of caval surgery required. 
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