Sunday, June 14, 2015
Over the many years I’ve been trying to perfect the art of surgery I’ve been involved with some truly interesting and amazing surgeries. By far, those cases which pique my interest the most are the retroperitoneal tumors. I don’t know if it’s the challenge of having navigate my way around an array of anatomic structures bearing names that are learned in first grade, such as aorta, kidney and pancreas, or the satisfaction that comes from knowing that successfully performing these operations gives the patient hope, or if it’s the joy of performing a truly anatomic dissection, but these are some of my favorite cases.
I know that I may face rebuke from my half a dozen fans for making such a statement, one which directly contradicts the Surgeon’s Prayer:”Lord, protect me from the interesting cases…,” but there is still a bit of the adventurous surgeon inside of me.
What is the Retroperitoneum? As the name implies it is the part of the abdomen which is retro, or behind, the peritoneum. The peritoneum is the thin membrane which covers much of our intraabdominal viscera or organs. The stomach, most of our intestines, the liver and spleen all lie within the peritoneal cavity. Behind this cavity, in the back of the abdomen lie the organs and blood vessels of the retroperitoneum. The pancreas, kidneys, ureters, adrenal glands, aorta and inferior vena cava are the retroperitoneum’s major structures; organs and blood vessels surgeons have learned should be accorded the utmost respect and avoided if at all possible.
“Stay away from the pancreas,” barked Dr. F.
“Find the Ureter,” commanded Dr. D.
“Be careful of the Vena Cava,” warned Dr. B.
I must have a masochistic bent to welcome potential calamity into my OR suite.
Eulie came to the office one day. She was sixty eight, in reasonably good health, only mild hypertension and had vague complaints of abdominal pain. She bore with her reports of her recent CT Scan of her abdomen and pelvis.
“Occlusion of the Inferior Vena Cava by thrombus or tumor 7.4 cm in length, starting above the renal veins and extending to below the confluence of the hepatic veins. Comparison with CT Scan performed on May 23, 2014 reveals the intraluminal mass has increased from 3.8 cm to its present size. Minimal flow is noted within the vena cava. Renal veins appear patent.”
Eulie had never had any symptoms suggestive of acute occlusion of the IVC and my first impression was that this was a tumor. Her physical exam was unremarkable.
“I think you are going to need surgery to remove what looks like a tumor in the Inferior Vena Cava,” I recommended. “I need to go over to the hospital to look at the actual images.”
The scope and intricate nature of the proposed surgery were explained and she left, surgery tentatively planned for two weeks hence.
“It looks like a tumor growing in the vena cava,” I commented as I scanned the recent CT Scan.
Dr. L, an exceptional radiologist, agreed.
“It looks like you should have a good cuff of Vena Cava below the hepatic veins to work with,” he observed.
“Yes, but I hope I’ll just have to ligate it. It looks like it’s been pretty much occluded for a year,” I replied, alluding to the scan from last year.
“Let me know what you find,” Dr. L. requested as I walked away.
I put Eulie out of my mind for the time being as I had plenty of other sick people to occupy my time.
Ten days later Eulie popped up again as her name appeared on my schedule for the following day planned to follow two cholecystectomies on two other patients.
The next morning I removed the two gallbladders in workmanlike fashion, warm ups for Eulie’s far more complicated surgery.
I made my usual preop visit to her and said hello to the large contingent of family and friends who would be waiting on her, then I went off to make rounds on a few patients while the staff prepared the operating room.
At nine twenty eight am Eulie was wheeled back to the OR, moved from stretcher to OR table and in less than ten minutes was asleep. The operation still had to wait while anesthesia personnel placed a central line, arterial line and the nurse placed a urinary catheter and cleansed her abdomen with the antiseptic solution: Chloraprep.
Finally they were ready for me. But, first the time out:
“Eulie ___, 68, DOB ___, she’s scheduled for resection of Vena Cava tumor, no allergies …”
I mumbled my agreement and we commenced.
I started with a long midline incision from xiphoid, which is the lower end of the breastbone, to just above the pubis.
A real operation for a change. No scopes, no monitors.
I really don’t have anything against minimally invasive surgery. Laparoscopic, thoracoscopic and endovascular approaches are much better for the patient. But, there is something about getting your hands into the patient, actually feeling the organs , normal and pathologic that adds a dimension to the surgery that is almost completely lost with laparoscopic approaches and absolutely absent from robotic surgery.
The firmness of the liver contrasting with the soft suppleness of normal bowel, the pulses of major arteries and the hardness of malignant tumors cannot be fully appreciated by the limited sense of touch transmitted through long laparoscopic instruments. William Halsted, the founder of the department of Surgery at Johns Hopkins Hospital eschewed the use of gloves because he did not want to lose the tactile sense he had with his bare hand. Bare handed surgery seems barbaric now, but back in those days the first rubber gloves were made for Dr. Halsted’s nurse, because her hands were sensitive to the mercuric chloride and carbolic acid used as antiseptics during surgery at that time. I wonder what Dr. Halsted would say now as we have almost given up the sense of touch during surgery. Progress?
Back to Eulie’s operation.
At first nothing unusual was seen in Eulie’s abdomen. No free fluid, no immediate signs of malignancy, just normal liver, stomach and bowel. I ran my hand over the presumed area of the Inferior Vena Cava and everything was soft, at first. But then as I palpated the area of the porta hepatis there was something hard behind the bile duct, portal vein and duodenum.
Time to start the surgery.
First there is mobilization and exposure. There were several layers of organs between me and the Inferior Vena Cava. First is the colon and omentum. Cut on the dotted line and bring the colon and omentum from right to left and five minutes later it’s out of my way, leaving the duodenum, porta hepatis and part of the pancreas to contend with.
Mobilizing these structures starts with a Kocher maneuver, named for surgeon of old Emil Theodor Kocher. The attachments of the duodenum to the retroperitoneum are divided which allows me to lift the duodenum and the head of the pancreas off the Inferior vena cava, leaving Big Blue (as the IVC is affectionately called by me) exposed.
At this point it is apparent that the mass in the IVC is not a clot; it is most definitely a tumor. The renal veins and aorta are also exposed. The tumor extends well into the retrohapatic cava. Proximal control will require a different approach.
I turn my attention to the IVC which is adjacent to the caudate lobe of the liver. This part of the IVC is one I usually wave at while doing hiatal hernia surgery as it is adjacent to the esophageal hiatus, which is where the esophagus passes through the diaphragm. Normally, I do my utmost to avoid any contact with it.
More mobilization, this time division of the lesser omentum and retraction of the left lobe of the liver and caudate lobe and the IVC is exposed again, this time almost behind the liver, but just above the tumor. Dissection of the vena cave even more proximally proved to be dicey as Big Blue took a dive towards the back. There was adequate vena cava to clamp above the tumor but reconstruction, if necessary would be a bit more problematic.
The final part of the dissection was to lift the porta hepatis off the vena cava and tumor. The porta consists of the extrahepatic bile ducts, hepatic artery and portal vein, all vital structures. Once again, the surgery gods shined their faces upon me as the porta hepatis was easily dissected free and retracted away from the cava.
And, there we were, me and the vena cava and the tumor, staring at each other. A moment of truth had been reached. The real operation was about to commence.
Dissect a bit more, perhaps. Mobilize the tumor away from the aorta and the free it from the tissue behind.
Now, do a bit of work around the kidneys, where there might be a bit of a problem. The left renal vein comes in right above the lower end of the tumor. The right Renal vein right below it, but leaving almost no way I can resect the tumor without doing something with the renal veins.
Left renal vein is no problem. Ligate it and all should be well. This vein can drain throught the gonadal and adrenal veins which branch off the left renal. These branches provide adequate collateral flow for the left renal vein.
But the Right Renal vein is an issue.
I’ll have to reimplant it somehow. I’ll deal with it later. Time to get the tumor out.
I started with the Ligasure, a marvelous device which seals and cuts blood vessels. This Ligasure eliminates the old clamp, clamp cut and tie, reducing a three minute maneuver to ten or fifteen seconds.
As I buzzed away, very efficiently I must say, I was forced to pause as blood started squirting at me, bright red, arterial blood. Suction was applied followed by my finger, right over the aorta. It seems my wonderful Ligasure was not very competent at sealing this particular vessel. Oh well, a bit of old fashioned halstedian surgery is good for the soul. I called for 4-0 Prolene and the small artery arising from the aorta was sutured with minimal fuss.
Was it just a minor annoyance? Or, a bit of ominous foreshadowing?
I continued on with my dissection until the vena cava and the tumor were completely free, both renal veins were dissected and I had adequate vena cava above and below the tumor to, at least, ligate.
The moment of truth had arrived.
The left renal vein was clamped and divided, then the right renal vein, followed by the retrohepatic cava. This vessel was clamped without any change in Emil’s vital signs and then the vena cava below the tumor was clamped, once again with no change in vital signs. Finally the vena cava itself was divided above and below the tumor which was removed and sent off to the waiting arms of the Pathologist for her gentle perusal.
Home free? But, where’s that blood coming from?
There was dark blood welling up adjacent to the liver from the area of the proximal clamp.
Just great, there’s a tear in the vena cava above the clamp.
“I need another vascular clamp,” I announced, hoping the tech was paying attention, “a straight clamp.”
Carefully, carefully I slip the clamp on the cava above the area which is bleeding and the pool of blood disappears into the suction, banished, forever I hope.
Doesn’t look like enough to sew. Maybe I can slide the clamp a few millimeters higher?
With as much care as I can muster I loosen the clamp enough to move it closer to the heart. This leaves me with about 5 millimeters of vena cava to work with. Plenty to ligate, but not enough to sew a graft.
OK, ligation should be good enough. The cava’s been completely occluded for at least a year anyway.
“4-0 Prolene, please,” I request and then I stick out my hand.
The suture appears, not rudely slapped into my palm, like TV or the movies, more gracefully, gently.
“I’ve never done a case like this,” the tech announces. “Is this like an aortic aneurysm.”
“Yes, only more so,” I answer.
Worse, much worse. If that clamp comes off before I finish sewing then poor Emil will be dead.
Think of having a big hole in the bottom of the heart.
But, it doesn’t come off, the cava is ligated successfully and I can finally breathe.
What next? The right Renal vein.
It won’t reach the cava. I guess I’ll need to make Big Blue a bit bigger. There is also a large lumbar vein which I’ve preserved, much larger than normal which suggests it may have been acting as an important collateral vessel.
“I need a graft, looks like a 20 mm Hemashield Platinum will work,” I announce, hoping the circulator is listening.
She is right on top of things, the graft is already in the room.
With minimal fuss I suture the graft to the clamped Vena Cava, reimplant the renal vein and the lumbar vein. The moment of truth arrives, the clamp is released and voila everything looks good.
Specifically, Emil has normal vital signs and there’s no bleeding anywhere. The Pathologist reports back and says the tumor looks like a sarcoma, the caval margins are free of tumor, but the cancer does extend to the radial margin, which means it has grown through the wall of the vena cava.
Nothing else to do. The duodenum was up against the tumor and I think the risk of resecting this far outweigh potential benefits.
“Number one PDS to close please.”
And so it went.
Emil’s recovery was marred by a brief episode of hypotension which responded to IV fluids and a couple of units of blood. She had a transient rise in BUN and Creatinine, but these rapidly returned to baseline and she was home in 5 days.
Emil was a case of knowing what is and is not possible. The left renal vein has collateral vessels which allow it to be ligated with minimal fuss. The right renal vein is not as forgiving. The Inferior Vena Cava lies deep within the retroperitoneum. Proper knowledge of how to expose and work around Big Blue should be a part of every general surgeon’s training. It is a vessel which can be most unforgiving if injured; sometimes trying to sew it is akin to putting stitches in wet tissue paper. Happily, this was not the case with Emil.
Complex surgery, like Emil’s, require some planning and forethought. What I mean by this is that after all the preoperative evaluation; the history, physical, blood tests and imaging is done, the plan for the actual operation needs development.
What incision is best?
How best to expose and control the vena cava?
Will anything need to be done with kidneys or their major vessels?
Will the vena cava need reconstruction or simple ligation?
These and other questions were mulled over again and again as I tried to anticipate each and every possibility. In Emil’s case all my planning led to a successful operation and outcome.
A few days after the surgery the Oncologist on the case stopped me.
“I read your operative note. I’ll bet your heart was racing during much of Emil’s surgery,” he commented.
“No, just all in a day’s work,” I lied.
We both smiled.