Surgical Strategy and Technical Operative Risks

A wide surgical exposure is mandatory for primary vascular control, tumor removal with associated lumbar fossa clearance, and aortocaval node dissection, with a possible extension to the adjacent organs and sometimes to the inferior vena cava. Therefore, a posterior approach is not indicated in these patients with large and often invasive tumors. There currently appears to be no place for laparoscopic surgery.

Some huge right-sided tumors, creeping behind the liver, still require a thoracoabdominal approach. In all other cases, either right- or left-sided, an extended subcostal transverse laparotomy is the best choice, with a view to possible extension by sternotomy if extensive inferior vena cava extension is suspected or present. Access to the right adrenal vein is difficult, especially in patients with large tumors. On the left side, by contrast, it is relatively easy if Catell's maneuver is used as a first step, combining mobilization of the right colon to the left and a Kocher maneuver to expose the left renal and adrenal veins at the vena cava before tumor manipulation.

All adjacent invaded organs should be resected while ensuring a functioning kidney on the contralateral side. Formal liver resection is rarely needed and may require vascular exclusion of the liver. Often, a cleavage plane can be found under the liver capsule. Left pancreatectomy with splenectomy is sometimes indicated on the left side for adequate resection of large invasive tumors. The adjacent kidney is rarely invaded by the tumor, but nephrectomy is often helpful, if there are dense adhesions, to obtain proper aortocaval clearance.

Liberal use of resorbable clips is recommended for adequate lymphostasis and sometimes for control of the thoracic duct at its origin.

Extension to the inferior vena cava is the major surgical challenge, especially on the right side (15% to 20% of cases). Direct invasion, if extensive, makes resection difficult and cure unlikely. Limited invasion can often be treated by wedge resection. Occasionally, segmental caval resection is necessary, with or without a graft, utilizing a bypass procedure. Limited intracaval thrombus can be flushed either directly27 or with a combination of caval clamping, vascular exclusion of the liver, and the use of a large Fogarty catheter in the atrium.28 If the thrombus extends superiorly to the right atrium, a thoracoabdominal or combined sternotomy-laparotomy is mandatory for primary control of the inferior vena cava in the pericardium. If it invades the right atrium, cardiopulmonary bypass with cardiac arrest is required. Use of external venovenous bypass remains controversial, but it appears to be useful in selected cases.129,30 A solitary liver metastasis should be removed when it can be done safely. Care must be taken to avoid rupturing the capsule to prevent local recurrence. We always use drains and recommend cryopreserving tumor tissue for subsequent biochemical and genetic studies.

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