Knacks and pitfalls of retroperitoneal sarcoma surgery, part 3: resection of tumors involving large retroperitoneal vessels.

Retroperitoneal sarcomas (RPSs) often involve major vessels such as the iliac arteries/veins, inferior vena cava (IVC), and abdominal aorta, posing significant surgical challenges. Resection of RPSs involving large vessels requires advanced vascular techniques and multidisciplinary collaboration. In Part 3 of this series, technical strategies, pitfalls, and case-based insights for managing RPSs with large vessel involvement are described based on operative experience at a high-volume sarcoma center. Surgical approaches to iliac vessels, IVC resection with or without tumor thrombus, and aortic contact are described. Iliac vessel involvement may require in situ or staged vascular grafting. IVC resection with or without reconstruction is feasible in the presence of a thrombus or direct invasion, but the resection depends on hemodynamic tolerance and collateral circulation. Tumors with IVC thrombus extending into the right atrium require cardiopulmonary bypass. Preoperative arterial embolization and intraoperative ultrasound help minimize blood loss and guide resection margins. Dissection without aortic resection is often possible even when the tumor is close to the abdominal aorta. RPSs with vascular invasion can be safely resected using tailored strategies if the institution is prepared. Surgical expertise in retroperitoneal vascular anatomy and collaboration across specialties are essential to ensure safe and effective oncologic outcomes.