Liver mobilization is essential for exposing the retrohepatic inferior vena cava (IVC) during level II-III robot-assisted IVC thrombectomy (RA-IVCT), but complex cases present significant challenges with a high risk of severe complications. This study aimed to evaluate the safety and feasibility of caudate lobectomy in facilitating retrohepatic IVC exposure in these complex cases.

Sixteen patients with complex level II-III IVC tumor thrombus (IVC-TT) underwent RA-IVCT with caudate lobectomy in our institution from January 2021 to November 2023. Thirty-two baseline-matched patients who underwent RA-IVCT without caudate lobectomy by equivalent experienced surgeons were included as controls. In cases requiring caudate lobectomy, the hepatic parenchyma was transected between the paracaval portion and the Spiegel’s lobe to improve exposure and control of the cephalic IVC using tourniquets.

All procedures were successfully completed. Five patients in the control group required conversion to open surgery compared to one patient in the caudate lobectomy group due to liver congestion. The caudate lobectomy group demonstrated significantly shorter liver mobilization times (138 vs. 188 minutes, p=0.044), reduced blood loss (1100 vs. 1900 mL, p=0.021), lower transfusion requirements (600 vs. 940 mL, p=0.033), and alleviated postoperative complications (p=0.035). Liver and kidney function, as well as short-term survival, were comparable between groups. Caudate lobectomy was shown to enhance exposure and control of the retrohepatic IVC during RA-IVCT.

Caudate lobectomy facilitates retrohepatic IVC exposure and control in complex level II-III IVC-TT, potentially simplifying surgery and improving perioperative outcomes.