A Surgical Video of an Ex Vivo Liver Resection with Autotransplantation in a Case with Extensive Inferior Vena Cava Leiomyosarcoma Extending to the Right Atrium with Atrial Septal Involvement and Complete Occlusion of All Major Hepatic Veins

Background: Leiomyosarcomas of the inferior vena cava (IVC) pose significant surgical challenges, particularly when tumors extend to the hepatic veins (HVs) and the heart. Such cases often necessitate innovative surgical strategies involving complex vascular and organ reconstruction.^{1, 2, 3, 4, 5–6} Patient and Methods: The patient is a 61-year-old female with a large expansile IVC leiomyosarcoma extending into the right atrium and involving the atrial septum. Imaging revealed complete occlusion of the IVC and all major HVs. Results: The tumor was resected en bloc, along with the whole liver, IVC, and portions of both atria under cardiopulmonary and portosystemic bypass. The atria and septum were reconstructed with bovine pericardial patches. The vena cava was reconstructed with a ringed Gore-Tex graft. Simultaneously at the back table, tumor resection and HV thrombectomy were performed. The hepatic vein outflow was reconstructed with a bovine pericardial patch. The tumor-free liver was then reimplanted. Operative time was 13 h 11 min, with an estimated blood loss of 4 L. The patient was then discharged home 1 month later. After 9 months, two small recurrent liver lesions were identified and addressed with partial liver resection following chemotherapy. The patient was alive and disease-free 16 months after initial surgery. Conclusions: This case highlights the successful use of ex vivo surgery and liver autotransplantation in managing an extensive IVC leiomyosarcoma. This innovative approach, combined with open heart surgery, achieved complete tumor resection with a reasonable postoperative recovery and oncologic outcome.