During a radical nephrectomy for a right renal cell carcinoma with inferior vena cava (IVC) thrombus extension to just below the hepatic veins (Mayo Level II), which vessel must be controlled first before IVC clamping?

• A Right adrenal vein
• B Right gonadal vein
• C Lumbar veins at the level of the thrombus
• D Contralateral left renal vein ✓

Explanation

In Mayo Level II IVC thrombus (above the hepatic veins but below the level requiring cardiopulmonary bypass), the contralateral left renal vein must be identified and controlled before IVC clamping to prevent venous hypertension in the left kidney and to avoid inadvertent injury. The left renal vein has multiple collaterals (gonadal, adrenal, lumbar) that can allow outflow even if temporarily clamped, but controlling it prevents back-bleeding into the operative field.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.