A ‘robot surgeon’ and a special suction cannula. These are the tools used by a team of the Niguarda hospital in Milan to remove a kidney tumor over 20 centimeters long and extending to the heart. They did so without opening either the chest or abdomen, in a minimally invasive way, choosing the path of ‘scar-free’ surgery for a fragile patient. Age: 83 years old. Today the hospital talks about the enterprise and assures us that it is an “intervention never attempted in the world”. A first in the operating room. Urologists and cardiac surgeons worked jointly with a specially designed technique, combining the use of the surgical robot and the suction cannula, inserted by the jugular to reach the heart. A ‘tailor-made’ technique for a delicate and complex operation: the tumor from the renal vein had completely infiltrated the vena cava to go up to the right atrium of the heart. Given the age and frailty of the patient, it was decided to put aside the ‘open surgery’. The record operation lasted 9 hours and saw the team of urologists and cardiac surgeons alternate at the operating table. Mission: to put the woman out of danger. “Given the advanced age and condition of the patient, who had recently undergone the implantation of two cardiac stents due to coronary heart disease, we opted for a minimally invasive procedure without abdominal incision and without opening the sternum – explains Aldo Bocciardi, Director of Urology – To do this we resorted to the use of the surgical robot, used to remove the kidney, seat of the tumor “. The forceps of the robot, inserted through abdominal micro-incisions, were also used to” remove the infiltrate neoplastic “that reached the heart. This was possible only after the cardiac surgeons had removed part of the cardiac infiltration thanks to the suction cannula, and then pushed the remaining part into the abdomen where the urologists with the robot were able to hook it and remove it completely. the world has been used the robot for kidney tumors extended to the vena cava; in the few cases where the disease reached the heart, it was never done with the robot and without opening the chest. The localization and extent of the infiltration required a rapid intervention to put the patient in safety. “This approach was possible thanks to the use of an innovative device – underlines Claudio Russo, director of Cardiac Surgery – The insertion of the suction cannula at the level of a vein in the neck, connected to a centrifugal pump and a filter, has allowed the high-flow tumor aspiration “. “The blood aspirated from inside the heart during surgery was filtered and re-introduced into the arterial circulation through another cannula placed at the height of the femoral artery – explains Russo – The high-flow circulation allowed for aspirate part of the tumor infiltrate and create a vacuum that like a suction cup hooked the neoplastic thrombus to push it into the abdomen, where it was possible to remove it with the robot “. Niguarda’s urologists and cardiac surgeons studied and point this intervention carried out together with the anesthesiologists nurses and all the operating room staff. “One of the biggest difficulties involved the extension of the infiltration that crossed an anatomical bottleneck represented by the diaphragm – indicates the cardiac surgeon Giuseppe Bruschi, first operator for the cardio part of the procedure – To overcome this we had to devise this double approach from the abdomen with the robot and with the aspirator inserted at the level of the neck, so as to be able to completely remove the kidney and the neoplastic infiltrate “. It is a very delicate phase” – adds urologist Antonio Galfano, the first operator who performed the different phases of the intervention from the robot console – concerned the ‘derotation’ of the liver, performed with the robot. With this maneuver the organ was temporarily moved from its natural seat to allow the passage of endoscopic surgical instruments for thrombus removal “.