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12cm right pheochromocytoma: not a contraindication to a laparoscopic approach

Laparoscopic adrenalectomy is now accepted as the procedure of choice for the resection of benign adrenocortical tumors. This video shows the laparoscopic approach for a 12cm right pheochromocytoma, demonstrating that the size is not a contraindication for laparoscopy.

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12cm right pheochromocytoma: not a contraindication to a laparoscopic approach

Autores

D Mutter, L Soler, J Marescaux

Resumen

Laparoscopic adrenalectomy is now accepted as the procedure of choice for the resection of benign adrenocortical tumors. This video shows the laparoscopic approach for a 12cm right pheochromocytoma, demonstrating that the size is not a contraindication for laparoscopy.

Clasificación

complex cases

Palabras clave

12cm right pheochromocytoma, no contraindication to laparoscopic approach

Tipo de medio

Vídeo quirúrgico

Duración

10'00''

Publicación

2010-02

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Subtítulos

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WeBSurg.com, Feb 2010;10(02).
URL: http://www.websurg.com/doi-vd01en2863.htm

12cm right pheochromocytoma: not a contraindication to a laparoscopic approach

1. Clinical case presentation 00'09''

A 60-year-old patient was admitted to our unit with the typical clinical signs of a pheochromocytoma associated with headaches, bouts of hypertension, and vomiting. As a result, a CT-scan was performed. The CT-scan demonstrated the presence of a 10 by 7cm right adrenal tumor. The endocrine workup confirmed a noradrenaline-secreting right pheochromocytoma with values superior to 100,000. A 3D-reconstruction of this pheochromocytoma confirmed its right adrenal location. It also demonstrates that it induces a large retraction of the liver cranially as well as a retraction of the kidney caudally.

2. 3D reconstruction 00'46''

The pheochromocytoma is surrounded by a highly distended venous vascular network, which is perfectly identified on this 3D reconstruction. This venous network is especially dense at the inferior portion of the tumor. The renal pedicle is also retracted caudally but it should not deter the laparoscopic dissection. An open laparoscopy is started at the umbilicus. The decision is made to attempt a laparoscopic resection before any potential conversion despite the size of the lesion, which does not comply at all with the usual resection criteria. The usual landmarks pertaining to the approach of the right adrenal gland will be employed.

3. Dissection of the liver\'s adhesions 01'40''

The adhesions to the liver’s inferior pole are taken down. The usual landmarks will be progressively searched for despite the size of the gland. The procedure will consist in the dissection of the upper and left lateral border of the gland successively in order to mobilize the liver cranially and identify the right lateral border of the inferior vena cava.

4. Vena cava dissection 02'16''

Contrarily to the usual technique, the size of the current tumor is an obstacle to the immediate full dissection. Consequently, the dissection must be carried out successively on the right border of the vena cava, and then back to the liver’s inferior pole in order to progressively mobilize the gland. This mobilization is made uneasy due to the size of the gland. As potential malignancy cannot be ruled out with regards to this pheochromocytoma, attention must be paid to avoid any rupture of the gland’s capsule. As can be seen here, the dissection is continued at the lateral border of the vena cava. The plane at the inferior and posterior pole of the vena cava is easily found. This allows to achieve an easy dissection of the lateral border of the vena cava from caudad to cephalad. The dissection is then extended towards the dihedral formed by the adrenal tumor and the liver in order to progressively identify the main adrenal vein. The anatomical landmarks are slightly modified due to the gland’s size and because of the liver’s retraction. Finally, as soon as traction is exerted on the tissues – though slightly more excessive than usual, a small bleeding may occur. It may be controlled either by monopolar cautery, or by bipolar cautery, or using the Ligasure® device.

5. Identification of the main adrenal vein 03'40''

The origin of the main adrenal vein is finally identified: this marks the first operative step. The main adrenal vein is in contact to a voluminous hepatic vein, which is isolated here and prepared in case its control should be performed using clips or ligatures. A few direct adhesions between the liver and the adrenal gland are taken down in order to isolate and circumnavigate the main adrenal vein safely. This step is essential in the surgical management of a pheochromocytoma. As performed usually in uneasy dissections of voluminous veins, the preparation of the vein is begun and a thread is passed around it in order to be manipulated safely. An attempt at applying clips is performed. Unfortunately, the size of the vein in relation to the gland’s size rapidly indicates that clips are insufficiently long to control this vein as it measures more than 1cm in width once prepared.

6. Division of the main adrenal vein 04'49''

The main adrenal vein is finally controlled and fully dissected using a white linear stapler (Endo-GIA). Once this main vein has been controlled, the patient’s blood pressure is stabilized, although the patient may still have occasional blood pressure rises. Dissection will successively approach all sides of the gland using either monopolar cautery with the hook when planes are perfectly identified, or bipolar cautery, or the Ligasure® device very comfortably. The lateral border of the vena cava is also dissected in a stepwise fashion in order to identify the adrenal arterial pedicles. It must be noted that the size of the lesion measuring more than 10cm modifies the anatomy of the region globally.

7. Dissection of the superior arterial pedicle 05'43''

Here it is probably an upper arterial pedicle, which is controlled with successive application of bipolar cautery using the Ligasure® device. Since the medial border of the gland has been totally freed, dissection is continued towards the medial angle formed by the renal vein and the inferior vena cava.

8. Dissection of the adrenal gland\'s lower pole 06'03''

The lower pole of the adrenal gland will be dissected until contact with the kidney. Here the voluminous veins surrounding the adrenal gland can be identified: they are first dissected and then controlled with bipolar cautery application using the Ligasure® device. In order to apply safe cautery, the right lateral border of the gland is further freed with division of the peritoneum. As a result, the upper pole of the kidney will be identified safely. Given that the position of anatomical structures of the kidney are modified due to the lesion’s size, the precise identification of the renal capsule is essential in order to make sure that there no residual arterial pedicular branches supplying the upper pole of the kidney. Part of the posterior freeing of the gland is performed simultaneously. Here the inferior freeing of the gland is achieved using multiple applications of cautery for safety reasons due to the size of these venous pedicles and large dilated veins around the adrenal tumor. The posterior inferior part as well as the posterior lateral part of the gland are progressively freed. The interest of such a progressive freeing is to make sure that the gland can be mobilized progressively once to the right and once to the left in order to have other structures exposed and placed under tension. To do so, there is a bipolar forceps in the operator’s left hand, and the Ligasure® device in the operator’s right hand.

9. Identification of the renal vein 08'04''

Here the renal vein is perfectly identified and the inferior polar artery is isolated and controlled once again using bipolar cautery with the Ligasure® device. This dissection is performed away from the renal artery’s pedicle safely. At this level, there is no risk of injuring a superior polar renal artery as perfectly identified during the 3D reconstruction. Then the posterior inferior part of the gland can be mobilized since the gland can be slightly retracted cranially and laterally at that time. Dissection is performed using bipolar cautery for the most part with the Ligasure® device. Large veins within the gland are also ligated.

10. Complete gland freeing 09'00''

Then the gland is progressively freed and mobilized and its inferior pole is also freed, thus removing the whole of the adrenal fossa. No manipulation of the gland is performed throughout this dissection to avoid any capsular rupture. Then the gland is totally freed of its attachments. It is introduced into an extraction bag. It is extracted after a slight enlargement of an umbilical incision. Since there is a hematoma at the centre of the tumor, its suction contributes to its extraction by limiting the skin incision. The operative field is bloodless at the end of the procedure. No drain is left in place.