3-Dimensional Laparoscopic Adrenalectomy and Evacuation of Inferior Vena Cava Tumor Thrombus

Introduction: Adrenal tumors with a tumor thrombus extending into the inferior vena cava (IVC) are extremely rare. These tumors are typically malignant and may be primary or secondary lesions. 1 , 2 The degree of tumor thrombus extension into the IVC can be classified from level I to level IV. 3 We present the 3-dimensional (3D) laparoscopic management of a secondary adrenal tumor with IVC tumor thrombus. To the best of our knowledge, this is the first video in literature depicting this minimally invasive technique. Materials and Methods: A 60-year-old male was referred by the oncologist with a right adrenal mass. This was found on regular follow-up imaging 7 years following a left-sided laparoscopic radical nephrectomy for organ confined renal cell carcinoma. On physical examination, he had a palpable lower pole of the right kidney. Computed Tomography (CT) imaging revealed a right-sided adrenal mass with a level I tumor thrombus extending into the IVC through the right adrenal vein. There was no evidence of tumor recurrent disease elsewhere. The left adrenal gland was normal. The mass was nonfunctional on laboratory investigations. It was suspected that this lesion is a metastasis secondary to the previous left-sided Renal Cell Carcinoma (RCC). A 3D laparoscopic adrenalectomy with evacuation of the IVC tumor thrombus and IVC reconstruction was performed. 3D glasses were worn by the surgical team during the procedure, which allowed 3D vision and depth perception. The key surgical steps are shown, including adrenal vein and IVC dissection, evacuation of the tumor thrombus, radical circumferential adrenal dissection, and IVC repair. Results: Intraoperative blood loss was minimal (50–100 mL). The patient’s postoperative recovery was uneventful, and he was discharged on postoperative day 3. The histopathology revealed renal cell carcinoma with clear resection margins. The patient has now survived 5 years following the procedure and is under the follow-up of the oncologist. Conclusions: An adrenal tumor with an IVC tumor thrombus is very rare but can potentially be managed with 3D laparoscopy, particularly if the degree of extension is low (i.e., level I). For successful management, a thorough patient work-up and meticulous surgical planning are paramount. The authors have no relevant financial or nonfinancial interests to disclose. Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. The authors declare that no funds, grants, or other support were received during the preparation of this article. Runtime of video: 9 mins and 44 secs.