Robotic Retrohepatic Inferior Vena Cava Thrombectomy with the 3C Technique: A Stepwise and Reproducible Approach for T3c Tumor Thrombus

Background Robot-assisted retrohepatic inferior vena cava (IVC) thrombectomy (RA-IVCT) is a high-risk procedure. We previously proposed caudate lobectomy for complex retrohepatic tumor thrombus, demonstrating safety and feasibility. Nonetheless, RA-IVCT for patients with tumor thrombus around the hepatic vein and involving the IVC wall (T3c disease) represents the most challenging scenario with a high complication rate. Objective To develop the stepwise and reproducible 3C technique, and to evaluate its feasibility and safety. Design, setting, and participants We conducted a comparative study of 12 patients who underwent RA-IVCT using the 3C technique, with 12 patients as controls who underwent the previously reported RA-IVCT technique. Surgical procedure The 3C technique is indicated for thrombus around the hepatic vein, suspected IVC wall invasion, and well-developed collateral circulation. First, suprahepatic IVC control was established. Second, a caudate lobectomy was performed via parenchymal transection between the paracaval portion and the Spiegel’s lobe. Third, tumor-bearing IVC cavectomy was performed through caudal-to-cephalic stapling. Measurements Baseline data, perioperative outcomes, and short-term survival rates were analyzed. Results and limitations All 3C procedures were completed robotically, whereas four controls required open conversion. The 3C group had a shorter liver mobilization time (126 min vs 182 min, p = 0.015), less blood loss (850 ml vs 2450 ml, p = 0.002), lower transfusion volume ( p = 0.005), and fewer complications ( p = 0.031). Organ function and survival rates were comparable. Limitations included small sample size, single-center experience, and nonrandomized design. Conclusions The 3C technique is a safe, stepwise, and reproducible robotic approach for retrohepatic tumor thrombus with IVC wall invasion.