Surgery of vena cava tumor thrombus of perirenal and subhepatic vena cava

According to the extension length of the tumor thrombus in the inferior vena cava, it can be divided into the following four types: 1 Peripheral vein type, the tumor thrombus does not exceed 2 cm above the renal vein opening. 2 Under the liver type, the tumor thrombus is more than 2 cm above the renal vein opening, but below the third hepatic inferior vena cava. 3 post-hepatic type, the tumor thrombus reached the posterior inferior vena cava, but below the diaphragm. 4 upper type, the tumor thrombus exceeds the transverse sputum, sometimes up to the right atrium. Preoperatively, the extent of vena cava tumor thrombus can be determined by CT or MRI. Sometimes it is necessary to undergo transesophageal ultrasound examination. Patients who cannot accurately determine the extent of tumor thrombus need to undergo antegrade and retrograde inferior vena cava angiography. For patients with renal cell carcinoma with inferior vena cava tumor, the prognosis depends on the stage of the tumor, pathological grade, local lymph node invasion and distant metastasis, and whether the tumor thrombus is removed during operation, and there is no significant relationship between the length of the tumor and the tumor in the inferior vena cava. . Therefore, patients with renal cancer with inferior vena cava tumor thrombus can still be actively treated. Treatment of diseases: kidney cancer contraindications 1. Patients with advanced tumors have dyscrasia. 2. There is a serious bleeding tendency, blood disease. 3. Patients with severe heart, lung and other organ diseases can not tolerate surgery. 4. Extensive transfer of multiple organs. Preoperative preparation 1. The tumor volume is too large, or blood is emitted, and renal artery embolization is feasible before surgery to make the tumor shrink for surgical removal and reduce intraoperative bleeding. 2. A large-scale renal embryonic tumor is treated with short-term (not more than 2 weeks) deep X-ray radiotherapy. 3. Patients with vena cava cancer suppository, MRI examination before surgery to determine the extent of tumor thrombus, if necessary, through esophageal ultrasound or vena cava angiography, to understand the upper and lower boundaries of the tumor thrombus and collateral circulation. 4. Preparation of mitomycin 20mg for intraoperative soaking wounds. 5. Leave the stomach tube and catheter before surgery. 6. Clean the enema before surgery. 7. Prepare blood. 8. Prepare the blood vessel suture device and the blood vessel suture. 9. Patients who need to undergo vena cava tumor thrombectomy should be treated with central venous cannulation. Surgical procedure 1. Incision is generally selected from the midline straight incision, up to the costal margin, down to the umbilicus 2 ~ 4cm, if necessary, add a chest joint incision. 2. Enter the abdominal cavity and expose the retroperitoneal cavity as described above. The renal artery and ureter are ligated and the renal vein is connected to the renal fascia. The renal vein is connected to it. Avoid unnecessary operation of the renal vein and vena cava to prevent the embolus from falling off. 3. Free the proximal and distal vena cava of the embolus, ligature and cut off the bilateral lumbar veins, and free the contralateral renal vein. An embolus with no obstruction around the renal vein. The partial vena cava can be clamped with a heart ear clamp. For the subhepatic vena cava tumor thrombus with obstruction, the distal and proximal vena cava should be completely freed, and if necessary, the liver should be ligated and cut. The caudal lobe enters the third hepatic small vessel of the vena cava, and the hepatic caudal lobe is gently turned up to expose the vena cava at the upper end of the tumor thrombus for effective control. The distal, proximal vena cava and contralateral renal vein were then clamped with a non-invasive vascular clamp. The inferior vena cava wall was incised and the tumor thrombus was removed. The vena cava lumen was repeatedly washed with distilled water. About 20% of the tumor thrombus may infiltrate the inferior vena cava wall, a small part of the vena cava wall infiltration may be part of the vena cava wall resection (the diameter of the tube is not reduced by more than 50% after resection and suturing), suture the vena cava incision with a 5-0 non-injury line . The gas should be emptied before suturing the vena cava incision. 4. Segmental inferior vena cava resection if the right renal tumor thrombus infiltrate the vena cava wall is large, after the partial vena cava wall resection can not ensure that the lumen is smooth (the diameter of the tube after resection and suture is reduced by more than 50%), you can Segmental inferior vena cava resection. The contralateral left renal vein is ligated at the proximal end of the adrenal central venous opening, and there is no need to rebuild the left renal venous circuit because of the abundant collateral reflux. For patients with left renal cell carcinoma with vena cava cancer, the reflow of the right renal vein after segmental vena cava resection may not be guaranteed, and the venous circuit should be reconstructed. Splenic and renal venous shunt, in situ vena cava anastomosis, and renal ectopic autografting can be used. However, if the vena cava tumor thrombus is completely obstructed, the right kidney may have established a relatively rich collateral circulation. After segmental vena cava resection, the right renal vein circuit may not need to be reconstructed, but the right kidney should be observed during surgery. Blood return and urine output. complication 1. After the operation, the blood was mostly caused by small blood vessel leakage, and the intraoperative blood pressure was low. Therefore, the operation should be carefully performed, and the cut small blood vessels should be carefully ligated, especially the distal end of the lumbar vein. Pay attention to the neovascularization of the tumor. 2. The chyle ascites is usually leaked into the lymphatic vessels of the chyle pool during systemic lymph node dissection. 3. Postoperative pneumonia and atelectasis are often caused by long incision, and the patient is restricted by breathing. In addition to encouraging deep breathing after surgery, nebulization can be given. 4. Incision infection and incision rupture often occur in poor general condition. Anemia and hypoproteinemia should be corrected before operation. When the peritoneal wound is soaked with mitomycin, the abdominal wall incision should be avoided and postoperative support treatment should be strengthened. Patients with concurrent chyluria and pancreatic leakage should be promptly explored for drainage and given high parenteral nutrition. 5. Functional intestinal obstruction is caused by colonic contact with renal fossa wounds, which can be relieved by itself. If necessary, gastrointestinal decompression can be resumed to recover from peristalsis. Patients with longer recovery time should be given intravenous high nutrition therapy. 6. Renal failure after segmental vena cava resection, contralateral renal venous return disorder caused. Left renal failure can gradually recover with the establishment of collateral circulation, which can be temporarily treated by hemodialysis. Right renal failure may require timely reconstitution of renal venous return.