Introduction/Background Advanced or recurrent gynecologic cancers with retroperitoneal lymphatic disease may involve the inferior vena cava (IVC), and achieving radical debulking of the disease in this scenario is challenging. The concept ’oncovascular surgery’ defines the case of tumor resection with simultaneous reconstruction of the great vessels when the tumor infiltrates or firmly adheres to the great vessels. The aim of this video is to demonstrate the surgical procedures for radical en bloc resection of metastatic lymph nodes and the infiltrated IVC followed by vascular reconstruction.
Methodology The indication for the debulking surgery was a first isolated recurrence of endometrioid endometrial cancer grade 2 (first diagnosis stage IB followed by external beam radiotherapy) in a 50-year-old patient with good performance status. Bulky precaval lymph nodes with infiltration of the IVC were identified, while other distant metastases were excluded. The multidisciplinary tumor board approved surgery as a treatment option.
Results The lymph node metastasis infiltrated the IVC with absence of a reliable dissection plane. After systemic heparin infusion and proximal and distal clamping of the vessel, we performed an en bloc resection of metastatic lymph nodes along with the infiltrated portion of the IVC. Subsequent vascular reconstruction was performed with a bovine patch. A Running suture (Prolene 5/0) was used to fix the patch in place. An intravascular heparin bolus was injected at the end of the procedure. Complete removal of macroscopic disease was achieved. No intraoperative or post-operative complications were observed.
Conclusion Tumor debulking with en bloc vascular resection and subsequent reconstruction is a feasible procedure, but requires accurate preoperative planning and an experienced surgical team. Gynecologic oncologists need to be familiar with the concept of ’oncovascular surgery’ in order to provide the best curative treatment even in the challenging case of advanced cancers with vascular involvement.
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