title: Robotic Transabdominal Control of the Suprahepatic, Infradiaphragmatic Vena Cava to Enable Level 3 Caval Tumor Thrombectomy: Pilot Study in a Perfused-Cadaver Model.
abstract: OBJECTIVE
  To develop a robotic technique for exclusively transabdominal control of the suprahepatic, infradiaphragmatic inferior vena cava (IVC) to enable level 3 IVC tumor thrombectomy.
  
  
  METHODS
  Robotic technique was developed in three fresh, perfused-model cadavers. Preoperatively, inflow (right jugular vein) and outflow (left femoral vein) cannulae were inserted and connected to a centrifugal pump to establish a 10 mmHg pressure in the IVC for the water-perfused cadaver model. Using a five-port transperitoneal robotic approach, the falciform ligament was detached from the anterior abdominal wall toward its junction with the diaphragm and tautly retracted caudally; this adequately retracted the liver caudally as well. Triangular and coronary ligaments were incised, allowing ready visualization of suprahepatic/infradiaphragmatic IVC and right/left main hepatic veins. Under direct robotic visualization, IVC was circumferentially mobilized, vessel-looped, and controlled.
  
  
  RESULTS
  All three robotic procedures were successfully completed transabdominally. Average robotic time to control the suprahepatic IVC was 37 minutes; in each case, the suprahepatic IVC was circumferentially controlled with a vessel-loop. There were no intraoperative complications. Length of the mobilized suprahepatic IVC measured between 2 and 3 cm. Right and left suprahepatic veins were clearly visualized in each case. Necropsy revealed no intra-abdominal/intrathoracic visceral or vascular injuries to the suprahepatic IVC, bilateral hepatic veins, or tributaries.
  
  
  CONCLUSIONS
  We developed a novel robotic technique for transabdominal control of the suprahepatic infradiaphragmatic IVC in a perfused human cadaver model. This approach may extend the application of advanced robotic techniques for the performance of major vena caval, hepatic, and level 3 IVC renal tumor thrombus surgery.
authors.affiliation: 1 Catherine & Joseph Aresty Department of Urology, USC Institute of Urology , University of Southern California, Los Angeles, California.
authors.forename: Andre Luis
authors.initials: AL
authors.lastname: de Castro Abreu
authors.affiliation: 1 Catherine & Joseph Aresty Department of Urology, USC Institute of Urology , University of Southern California, Los Angeles, California.
authors.forename: Sameer
authors.initials: S
authors.lastname: Chopra
authors.affiliation: 2 Urology Department, King Abdulaziz University, Jeddah, Saudi Arabia .
authors.forename: Raed A
authors.initials: RA
authors.lastname: Azhar
authors.affiliation: 1 Catherine & Joseph Aresty Department of Urology, USC Institute of Urology , University of Southern California, Los Angeles, California.
authors.forename: Andre K
authors.initials: AK
authors.lastname: Berger
authors.affiliation: 1 Catherine & Joseph Aresty Department of Urology, USC Institute of Urology , University of Southern California, Los Angeles, California.
authors.forename: Charles
authors.initials: C
authors.lastname: Metcalfe
authors.affiliation: 3 Department of Surgery, Surgical Skills Simulation & Education Center, Keck School of Medicine, University of Southern California , Los Angeles, California.
authors.forename: Michael
authors.initials: M
authors.lastname: Minetti
authors.affiliation: 3 Department of Surgery, Surgical Skills Simulation & Education Center, Keck School of Medicine, University of Southern California , Los Angeles, California.
authors.forename: Joseph N
authors.initials: JN
authors.lastname: Carey
authors.affiliation: 1 Catherine & Joseph Aresty Department of Urology, USC Institute of Urology , University of Southern California, Los Angeles, California.
authors.forename: Osamu
authors.initials: O
authors.lastname: Ukimura
authors.affiliation: 1 Catherine & Joseph Aresty Department of Urology, USC Institute of Urology , University of Southern California, Los Angeles, California.
authors.forename: Mihir
authors.initials: M
authors.lastname: Desai
authors.affiliation: 1 Catherine & Joseph Aresty Department of Urology, USC Institute of Urology , University of Southern California, Los Angeles, California.
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D000368:Aged; D002102:Cadaver; D002292:Carcinoma, Renal Cell / Q000601:surgery*; D005240:Feasibility Studies; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery*; D008297:Male; D010477:Perfusion; D010865:Pilot Projects; D011312:Pressure; D065287:Robotic Surgical Procedures / Q000379:methods*; D017131:Thrombectomy / Q000379:methods*; D013927:Thrombosis / Q000601:surgery; D014682:Vena Cava, Inferior / Q000473:pathology*