Editing Open Kidney Surgery (section)

==== Level II vena caval thrombectomy ====

* Surgical plan (for left-sided tumor)
**Position: anterior midline and chevron incisions provide the best access for left-sided tumors associated with tumor thrombi in the IVC.
***'''Exposure for a tumor thrombus associated with a left-sided tumor is more difficult since the IVC is best accessed from the right retroperitoneum.''' 
****Both the right and the left colon have to be mobilized to get adequate exposure. 
**Medialize the left colon and develop anterior pararenal space. 
**Identify and ligate the left renal artery near its origin close to the aorta. 
**Identify and ligate the adrenal, lumbar, and gonadal branches of the left renal vein. These branches are often dilated and friable and occasionally contain thrombi. 
**Mobilize the kidney outside the renal fascia and divide the ureter. 
**Medialize the right colon, small bowel, and duodenum
**Develop the right anterior space
**Expose the great vessels.
**Carefully dissect the IVC to its bifurcation, ligating the right gonadal vein on its anterior surface.
***To gain 2 to 3 cm of extra infrahepatic IVC exposure, accessory hepatic veins are ligated to the caudate lobe (this is an optional maneuver).
**'''Obtain vascular control sequentially in the following order:'''
**#'''Ligate the ipsilateral (left) renal artery'''
**#'''Clamp the infrarenal IVC'''
**#'''Clamp the contralateral (right) renal vein'''
**#'''Clamp the suprarenal IVC'''
**##Optionally, one can clamp the contralateral renal artery to prevent renal engorgement while the venous outflow is temporarily clamped. 
**###More of an issue for left-sided tumors since unlike the left kidney, the right kidney does not have significant venous collateralization to shunt blood when the right renal vein is clamped. 
**##While obtaining vascular control, one must be very gentle to avoid dislodging the thrombus. 
**##Ligate and divide the lumbar veins, as required. 
**##Prior to clamping, some may use 0.5 mg/kg of intravenous heparin to prevent clamp-related thrombotic complications. This may increase bleeding and some do not routinely heparinize our patients.
**'''Excise the renal vein ostium circumferentially excised and extend the incision superiorly onto the anterior surface of the IVC using Potts scissors.''' 
***Use a Penfield dissector to carefully extract the tumor thrombus from the IVC. 
***Lumbar veins can be a source of troublesome bleeding at this stage and should be ligated or sutured as needed
**'''Remove the gross tumor thrombus and kidney en bloc.'''
**'''Irrigate IVC lumen with heparinized saline (100 units/mL) and inspect the intima for signs of caval invasion.''' Any suspicious areas should be biopsied or resected. 
**'''Close the caval defect with a running 4-0 Prolene suture.''' 
***'''The IVC lumen can be safely narrowed to about 50% of its preoperative size without requiring special measures.''' 
***'''Prior to tying the knot, the infrarenal clamp is released''' and 5 to 10 mL of blood is allowed to seep from the cavotomy to clear the IVC of air and debris. 
***'''After tying the suture, the contralateral renal vein clamp is released followed by the suprarenal IVC clamp.'''
* '''<span style="color:#ff0000">When performing right radical nephrectomy with tumor thrombectomy, the suprarenal IVC can be resected, but only if the left renal vein has been ligated distal to its venous tributaries (i.e., gonadal, lumbar, and adrenal veins). This will allow the left renal vein to drain through these tributaries. Given the lack of venous tributaries on the right side, the suprarenal IVC should not be resected for a left-sided tumor unless one provides alternative venous drainage for the right kidney with autotransplantation or a saphenous vein graft to the splenic, portal, or inferior mesenteric vein.</span>'''
* Regional lymphadenectomy is performed, consideration is given to leaving a closed suction drain, and the wound is irrigated and the incision closed.