a 61-year - old man presented to a community hospital with a 4-month history of fatigue and a 45-kg weight loss .
g / l , a 12-cm right - sided renal mass , and a 3-cm right - sided adrenal mass . after receiving four units of packed red blood cells ,
the patient was discharged home and referred to our institution for definitive management . on initial evaluation at our institution , his vital signs were stable and his body mass index was 43.5 kg / m . on examination , the patient had a soft , nontender abdomen with a large pannus and no palpable masses .
staging imaging showed an enhancing 12.010.7-cm right upper pole mass with an adjacent 3.5-cm adrenal nodule and evidence of a possible subhepatic ivc thrombus ( fig .
a computed tomography scan of the chest showed no metastases , and the results of a bone scan were also negative .
mol / l , liver enzyme concentrations were within normal limits , and the hemoglobin concentration was 82
the patient was taken to the operating room for a robotic , possibly open , radical nephrectomy with caval thrombectomy . a vascular surgeon , a hepatobiliary surgeon , and an experienced uro - oncologist were consulted and available for intraoperative assistance .
2 ) and the robot was docked , the ascending colon was reflected medially , the duodenum was kocherized , and the ivc was exposed .
the liver extended beyond the lower pole of the kidney and was sufficiently large enough that a single 5-mm grasper was unable to hold the weight of the liver .
thus , another 5-mm assistant port was placed lateral to the initial 5-mm assistant port to help hold the liver off of the kidney ( fig .
2 ) . the renal artery was identified and transected , by using a standard laparoscopic stapling device , in the interaortocaval space to minimize handling of the ivc and thrombus - filled right renal vein .
the ivc was then dissected circumferentially above and below the right renal vein ; two gonadal veins were clipped and transected , which left a 1.5-cm stump on both , and the right adrenal vein and two lumbar veins were also clipped and transected .
once the kidney was completely mobilized , except for its lateral attachments to the abdominal wall , the fourth robotic arm was docked and used to provide lateral retraction of the kidney .
3 ) . after it was confirmed that the thrombus was not adherent to the ivc wall , that there was no bland thrombus below the tumor thrombus , and that we had adequately mobilized the ivc above the upper limit of the thrombus , the vessel loops were wrapped twice around the ivc above and below the thrombus and around the left renal vein . despite angioembolization
1 week previously and lateral retraction of the kidney , the thrombus was found to extend far enough into the ivc to necessitate complete cross - clamping of the ivc ; tangential exclusion of the thrombus alone , with the use of a laparoscopic satinksy clamp , was not deemed feasible based on the results of intraoperative ultrasonography .
the vessel loops were used to create modified - rummel tourniquets as described by abaza , and the ivc was completely cross - clamped starting with the most cranial ivc vessel loop ( fig .
with the vessel loops cinched down completely and secured by hem - o - lok clips ( teleflex inc .
, limerick , pa , usa ) , a small incision was made in one of the gonadal vein stumps to test the hemostasis within the cross - clamped portion of the ivc .
because of continuous bleeding , the gonadal vein stump was religated , the tourniquets were released , and a careful search for another source of inflow to the ivc was initiated . just above the left renal vein and below our cephalad tourniquet , a missed lumbar vein was identified entering into the ivc posteriorly .
after this vein was ligated with clips and the ivc was reclamped , the second gonadal vein stump was incised , and no further venous flow was observed . as such , an incision was made in the wall of the ivc to expose the ivc thrombus , which was delivered intact on complete transection of the renal vein ( fig .
4 ) . after the ivc lumen was irrigated with heparinized saline , a van velthoven - style   double - arm 4 - 0 prolene suture was used to close the ivc in two layers , which maintained at least 50% luminal caliber ( fig .
4 ) . before the ivc was closed , the caudal ivc tourniquet was loosened to vent any clot or debris within the ivc and to test the closure .
after adequate hemostasis was achieved , the thrombus was transected at the level of the renal vein and placed into a small entrapment sac to prevent contamination of the peritoneal space .
the right adrenal gland was taken en bloc with the kidney , which was then mobilized free of its remaining superolateral attachments .
the specimen was removed through a modified - gibson incision created by connecting the fourth robotic arm port and the 12-mm assistant port in the right lower quadrant .
the entire procedure was performed by two robotic surgeons early on in their learning experience ( < 25 robotic cases performed ) ; console time was alternated between the two surgeons , and one surgeon remained at the patient 's bedside at all times .
the total operative time was 527 minutes , and the total ivc cross - clamp time was 15 minutes . because of adhesions from a prior laparoscopic cholecystectomy and significant hepatomegaly , it took 90 minutes to mobilize the liver off the kidney , to place two laparoscopic locking graspers to retract the liver , and to manage a small liver laceration that occurred during mobilization ; direct pressure with application of floseal ( baxter healthcare inc . ,
the total estimated blood loss was 750 ml , half of which was accounted for by the ivc cross - clamp tests . because the preoperative hemoglobin concentration was only 82
g / l , two units of packed red blood cells were transfused before the operation began , and two additional units were transfused postoperatively .
the initial postoperative hemoglobin concentration was 90 g / l , and the hemoglobin concentration at the time of discharge was 95
a moderate - sized pneumothorax was identified on chest x - ray , which was likely related to the two locking graspers placed on the diaphragm and was used to retract the liver ; therefore , a right - sided chest tube was required .
the patient required 11.7 mg of a morphine - equivalent dose of intravenous narcotics during the initial 48 hours postoperatively and was then managed with oral antiinflammatory agents only .
4 ) , evidence of tumor extension through the renal capsule into the perinephric fat , and thrombus positive for malignancy ( pt3b ) .
the patient was found to have bilateral deep venous thrombus on postoperative day 11 ; thus , the patient was briefly admitted to the hospital for initiation of anticoagulation therapy .
the patient was also referred to a hematologic oncologist for consideration of adjuvant therapy and is currently scheduled for restaging imaging at 8 weeks postoperatively .
reports of the use of combined laparoscopic - open [ 4 - 6 ] and hand - assisted laparoscopic   approaches to treat renal tumors with an ivc thrombus have been reported .
a single case report of a purely laparoscopic technique has also been published . however , none of these cases required complete cross - clamping of the ivc .
this technically challenging task has limited the application of mis techniques to more advanced t3b tumors .
the recently published case series of a purely robotic approach , however , did involve complete cross - clamping in 2 of 5 patients .
although these reports indicate the successful use of mis techniques to manage advanced renal tumors , critics continue to question the safety and general feasibility of such applications .
although it is true that the mis approach to treat such complex tumors remains investigational , the advent of the robotic surgical platform may mitigate the technical challenges that prevent the acceptance and adoption of such approaches . using an experienced laparoscopic bedside assistant and after significant preoperative preparation and planning ,
two relatively novice robotic surgeons were able to perform a purely robotic radical nephrectomy with caval thrombectomy requiring complete cross - clamping of the ivc , which was aided significantly by the improved precision and dexterity of the robotic platform .
although the current case report and the case series reported by abaza   provide initial validation of the feasibility of this technique , the utility of a purely robotic approach to t3b renal tumors undoubtedly remains highly investigational .
the authors believe , however , that continued application of such innovative techniques is necessary to optimize the surgical care that we deliver to our patients .
 the introduction of robot - assisted laparoscopic surgery has facilitated the application of minimally invasive surgical techniques to many complex reconstructive and extirpative procedures . 
 even early on in their learning experience , robotic surgeons have been able to complete procedures using a minimally invasive approach , but would not have been able to do so using a purely laparoscopic technique . although the open surgical approach remains the standard of care in the management of large renal tumors presenting with a thrombus within the vena cava , robot - assisted surgery may provide the precision and dexterity necessary to allow for the safe application of minimally invasive techniques to such complex clinical scenarios , perhaps even by relatively novice robotic surgeons . 
 we describe the management of a large renal mass with vena caval thrombus ( ct3b ) , which required complete cross - clamping of the vena cava , with the use of a purely robot - assisted laparoscopic approach . 
CASE REPORT
DISCUSSION