Resection of Retro-Hepatic Vena Cava (RHVC) En-bloc with Caudate Lobe without Vascular Exclusion for a Low Grade Leiomyosarcoma of Inferior Vena Cava



Leiomyosarcomas (LMS) of the inferior vena cava (IVC) originate in the retrohepatic (RHVC) portion in 15% of cases.1 Due to complex anatomy and need to preserve venous outflow from the infra-diaphragmatic viscera, the operation may require total vascular exclusion, veno-venous bypass and hypothermic liver resections.2,3 In this video, virtual planning of the operation allowed a parenchyma-sparing radical resection in a patient with limited liver reserve.


A 12-cm LMS of RHVC invading the entire segment 1 (i.e., Spiegel’s lobe, paracaval portion, and caudate process) was diagnosed in a man with metabolic steato-hepatitis (BMI: 34). He had no response to previous chemotherapy. Major hepatectomy was excluded considering the high risk of postoperative liver failure. 3D-reconstruction of regional anatomy allowed planning of a parenchymal-sparing, en bloc resection of tumor, RHVC, and caudate lobe while avoiding hilar and suprahepatic venous clamping.


The operation strategy relied on the en bloc separation of caudate lobe, RHVC, and tumor from the hepatic veins confluence and the posterior segments after complete mobilization of the liver. Vessel loop-assisted hanging maneuver, encircling tumor, and RHVC with superimposed 3D-reconstructions guided the parenchymal transection, while preserving the middle hepatic vein outflow. RHVC was replaced with prosthetic material.


Complex resection of primary tumor of the IVC en bloc with caudate lobe and RHVC can be attempted in chronic liver diseases at-risk of postoperative failure. Preservations of transhepatic flow and liver function depends on tumor size and preservation of noninvaded hepatic-veins confluence. Preoperative virtual 3D reconstruction is crucial in surgical planning.


  1. 1.

    Kulaylat MN, Karakousis CP, Doerr RJ, Karamanoukian HL, O’Brien J, Peer R. Leiomyosarcoma of the inferior vena cava: a clinicopathologic review and report of three cases. J Surg Oncol. 1997.

    Article  PubMed  Google Scholar 

  2. 2.

    Ravaioli M, et al. Liver and vena cava en bloc resection for an invasive leiomyosarcoma causing Budd–Chiari Syndrome, under veno-venous bypass and liver hypothermic perfusion: liver hypothermic perfusion and veno-venous bypass for inferior vena cava leiomyosarcoma. Ann Surg Oncol. 2017.

    Article  PubMed  Google Scholar 

  3. 3.

    Hardwigsen J, Balandraud P, Ananian P, et al. Leiomyosarcoma of the retrohepatic portion of the inferior vena cava: clinical presentation and surgical management in five patients. J Am Coll Surg. 2005.

    Article  PubMed  Google Scholar 

Download references


Open access funding provided by Università degli Studi di Milano within the CRUI-CARE Agreement.

Author information



Corresponding author

Correspondence to Vincenzo Mazzaferro MD, PhD.

Ethics declarations


All authors declare not to have any commercial interest in the subject of study and that there is no source of any financial or material support.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (MP4 328446 kb)

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Altomare, M., Sposito, C., Regalia, E. et al. Resection of Retro-Hepatic Vena Cava (RHVC) En-bloc with Caudate Lobe without Vascular Exclusion for a Low Grade Leiomyosarcoma of Inferior Vena Cava. Ann Surg Oncol (2021).

Download citation


  • Augmented reality
  • 3D virtual reconstruction
  • Transplant surgery
  • Sarcoma surgery
  • Inferior vena cava