Groundbreaking robotic surgery successfully removes stage IV tumor thrombus

After nearly 10 hours, a surgical team at Keck School of Medicine of the University of Southern California (USC) completed the first robotic, minimally-invasive surgical removal of a stage IV tumor thrombus. The team consisted of three surgeons, a critical-care anesthesiologist, and a radiologist.

Surgery for a stage IV tumor thrombus is typically traumatic, requires several quarts of blood, and is inherently risky—patients have a 1 in 20 chance of dying during the procedure. It is a major open procedure that requires constant monitoring of the patient and the thrombus to ensure the thrombus does not break.

The robotic technique can significantly reduce trauma and decrease the need for transfused blood by nearly 5-fold. This patient’s hospital stay lasted only 6 days, as opposed to the 2 to 3 weeks required with the open procedure. In additional, overall recovery time was reduced significantly.

This surgery lays the groundwork for incorporating advanced technology to create higher standards of patient care, even in complex cases.

“This exciting feat promises to redefine the boundaries of what is surgically possible through skill, collaboration, and technology,” said Inderbir S. Gill, MD, who led the multidisciplinary surgical team. “Our hope is that we can now propel the field at large to turn such futuristic robotic surgery into our present standard-of-care.”

The timeline

Prior to the surgery, Vinay Duddalwar, MD, Associate Professor of Clinical Radiology, created a 3D animated map of the patient’s chest and abdomen. This allowed the surgeons to create a strategy with millimeter precision.

Namir Katkhouda, MD, PhD, Professor of Surgery, kicked off the procedure with a surgical maneuver to control blood flow to the patient’s liver. Dr. Gill then employed the latest-generation da Vinci Xi surgical robot to completely dissect the tumor-bearing kidney through small keyhole incisions in the patient’s abdomen. This allowed control over various blood vessels and created access around and into the inferior vena cava, where the cancer had spread.

Mark Cunningham, MD, Associate Professor of Surgery, placed the patient on a heart-lung bypass machine that created a bloodless environment for tumor removal.

He then created a minimally invasive incision through the ribcage to open the patient’s heart. Drs. Cunningham and Gill worked simultaneously to remove the tumor thrombus from the heart and inferior vena cava, respectively. Dr. Cunningham worked from the chest downward, and Dr. Gill worked from the abdomen upward.

Intraoperatively, Duraiyah Thangathurai, MD, Professor of Clinical Anesthesiology and Chief of Critical Care Medicine, monitored the patient’s organ function. He kept watch over the patient’s heart using an esophageal echo probe. If a portion of the tumor were to break off into the heart or lungs, the patient would die instantly.

“We are proud of our ability to coordinate such complex efforts between the cardiac and urologic surgical teams with skill and dexterity,” said Dr. Cunningham. “This was the driver of our success and exactly the standard we strive for across the institution.”