Editorial Comment for Abreu et al.

Surgical innovation is a hazardous path, particularly with high-risk and complex conditions. Applying minimally invasive techniques to operations fraught with peril even when performed in traditional, open fashion is controversial at best and possibly irresponsible at its worst. One method for responsible application of minimally invasive surgery to complex surgeries is to slowly progress from the least to most difficult of the procedures in question with initially strict patient selection.

This method has heretofore been successful for robotic management of inferior vena cava (IVC) thrombi, which began with short thrombi extractable with tangential IVC clamping (as had been described laparoscopically before) and progressed to large thrombi necessitating complete IVC cross-clamping (which had not). ¹ The authors are one of two groups who have described the step that followed, applying these methods to level III thrombi above the short hepatic veins but below the main hepatic veins as cited in their current work.

Another method even more safe and commendable is most appropriate for the procedures with least room for error and where more things can go wrong. The authors are wise for choosing to use a cadaveric model to explore the next step in robotic caval thrombectomies: Thrombi at or above the main hepatic veins, which will necessitate the ability to control the suprahepatic, infradiaphragmatic IVC.

The I.D.E.A.L. model (Idea, Development, Exploration, Assessment, Long-term follow-up) developed by the Balliol Collaboration offers a responsible framework for surgical innovation. ² Phase I of the original model does not begin with cadavers or simulation, though, but rather with limited application in human patients. For some procedures, this may not be truly ideal, such as in the development of a robotic kidney transplantation procedure where Phase 0 cadaveric modeling allowed success from the very first patient. ³

The authors are congratulated on their cadaveric work demonstrating that the infradiaphragmatic IVC is accessible robotically, a critical maneuver worthy of Phase 0 exploration before attempts in patients. Although in these cadavers they did not go so far as to combine this with the steps previously achieved to complete a simulation of robotic management of high intrahepatic thrombi, the step they demonstrated is a necessary one to allow safe application of such a procedure in human patients. One small step for robotic surgery, one large step for intracorporeal management of level III IVC thrombi.