99: Technique of IVC Resection and Replacement During Liver Resection

Saturday, March 25, 2023

10:53 AM – 11:06 AM

Location: Veterans Memorial Auditorium

Video Presenter(s)

Moran Slavin, MD (she/her/hers)

Advanced Foregut and HPB Fellow
Digestive Health Institute Tampa
Tampa, Florida, United States

Disclosure(s): No financial relationships to disclose

First Author(s)

SR

Sharona Ross, MD FSSO

Director Foregut and Pancreatic Surgery
Digestive Health Institute Tampa
Tampa, Florida, United States

Disclosure(s): Intuitive Surgical: Consultant (Ongoing), Speaker (Ongoing)

Author(s)

Iswanto Sucandy MD FACS, MD, FACS

Associate Professor of Surgery, University of Central Florida, College of Medicine Advanced Gastrointestinal Surgery | Hepatobiliary and Pancreatic Surgery
AdventHealth Tampa, Florida, United States

Disclosure(s): No financial relationships to disclose

Author(s)

Iswanto Sucandy MD FACS, MD, FACS

Associate Professor of Surgery, University of Central Florida, College of Medicine Advanced Gastrointestinal Surgery | Hepatobiliary and Pancreatic Surgery
AdventHealth Tampa, Florida, United States

Disclosure(s): No financial relationships to disclose
KC

Kaitlyn Crespo, BS

Research Coordinator
AdventHealth Tampa, United States

Disclosure information not submitted.
AR

Alexander Rosemurgy, MD FACS FSSO

Attending HPB Surgeon
Digestive Health Institute Tampa, United States

Disclosure information not submitted.

Disclosure(s):

Moran Slavin, MD: No financial relationships to disclose

Sharona Ross, MD FSSO: Intuitive Surgical: Consultant (Ongoing), Speaker (Ongoing)

Iswanto Sucandy MD FACS, MD, FACS: No financial relationships to disclose

Introduction: Liver resection for centrally located aggressive liver tumors such as for those located in segments 8 or 1 often require vascular resection and reconstruction. Lack of open vascular surgery experience, fear of major bleeding and concerns of hemodynamic instability during inferior vena cava (IVC) clamping requiring veno-venous bypass (VVB) are limiting factors for many surgical oncologists, especially those in early career. While liver resection provides the only chance for cure in such patients, educational description of technique for IVC resection and replacement is limited. In this video, we describe our method of IVC resection and reconstruction/replacement during hepatectomy without VVB.

Methods:

This video details three patients who underwent open IVC resection and reconstruction/replacement for centrally located liver tumors.

Results: Preoperative workup included CT scan, MRI, or 3D liver volumetric imaging to assess the tumor location, relations to major vessels, and liver volumes. With each operation, access to the abdomen was obtained through a right upper transverse incision with upper midline extension. An Omni retractor was utilized to achieve adequate exposure to the upper abdomen. Lysis of adhesions was undertaken to fully mobilize the liver and expose the IVC. The first operation demonstrates a two-stage right hepatectomy involving the resection of the right lobe of the liver for intrahepatic cholangiocarcinoma invading the hepatocaval confluence and IVC. The second and third operations involve the enbloc resection of the caudate lobe with retrohepatic IVC due to circumferential tumor invasion into the IVC. IVC cross-clamping was undertaken for 30 minutes during IVC replacement using a 16mm woven dacron graft. The proximal and distal anastomoses were constructed using a running 3-0 prolene sutures starting from 6 0’clock to 12 o’clock. All of the patients maintained hemodynamic stability without the need for VVB. All patients tolerated the procedure well and were discharged home within a week without postoperative complications. Final pathology confirmed 8.5 cm intrahepatic cholangiocarcinoma, 10 cm HCC, and 4.5 cm leiomyosarcoma lesions, respectively. R-0 margins were obtained. At 3-year follow-up, all patients are disease-free.

Conclusions: This video depicts the safety and efficacy of IVC resection and replacement for liver tumors that involve the IVC.

Learning Objectives:

Upon completion, the participants will be able to understand surgical option for a centrally located liver cancer involving IVC.
Upon completion, the participants will be able to recognize the operative technique/steps during IVC resection and reconstruction/repair.
Upon completion, the participants will be able to understand favorable clinical and oncological outcomes of enbloc liver and IVC resection for various liver tumors.