Purpose: Level III thrombus in the inferior vena cava poses a challenge to the surgeon due to its relative inaccessibility. We introduce a new system to redefine level III thrombus in anatomical relation to the hepatic veins and describe a technique of safe resection of these tumors through a transabdominal approach without recourse to cardiopulmonary bypass.
Materials and methods: From August 1997 to July 2001, 23 patients underwent resection of renal cell carcinoma with a level III thrombus. Intraoperative as well as postoperative variables such as operative time, estimated blood loss, number of transfusions, cardiopulmonary bypass, postoperative complications, pathological findings and survival were recorded.
Results: A total of 15 male and 8 female patients with a mean age of 62 years (range 25 to 83) underwent resection of a level III thrombus emanating from renal cell carcinoma. Patients were divided into groups IIIa-9 with an infrahepatic thrombus, IIIb-6 with a hepatic thrombus, IIIc-5 with a suprahepatic, infradiaphragmatic thrombus and IIId-3 with a suprahepatic, supradiaphragmatic, infra-atrial thrombus. Mean operative time was 5 hours 42 minutes (range 4 to 7.5 hours). The number of transfusions was 0 to 4. Estimated blood loss was 100 to 5,000 cc (mean 500). Neither cardiopulmonary bypass nor veno-venous bypass was required. Median followup was 25 months. Two patients (9%) died, including 1 in the immediate postoperative period and the other from metastasis 15 months after surgery. At the last followup 3 patients (13%) had metastasis and 18 (78%) were disease-free for overall and disease-free survival rates of 91% and 78%, respectively.
Conclusions: An aggressive surgical approach remains the mainstay of treatment to achieve cure. We believe that the extent of dissection is different in each subgroup and, therefore, the need exists to redefine level III thrombus of the inferior vena cava. The application of liver transplant techniques for mobilizing the liver off of the inferior vena cava as well as the inferior vena cava off of the posterior abdominal wall contributes to excellent exposure and enables adequate vascular control of the inferior vena cava.