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Difficult laparoscopic right adrenalectomy due to intraoperative adhesion

Laparoscopic adrenalectomy has become increasingly used and has now become the technique of choice for most benign adrenal lesions due to decreased blood loss, lower morbidity, shorter hospital stay, faster recovery, and overall cost-effectiveness as compared with the open approach. This video shows a laparoscopic live trans-abdominal right adrenalectomy.

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Difficult laparoscopic right adrenalectomy due to intraoperative adhesion

作者群

D Mutter, L Soler, J Marescaux

摘要

Laparoscopic adrenalectomy has become increasingly used and has now become the technique of choice for most benign adrenal lesions due to decreased blood loss, lower morbidity, shorter hospital stay, faster recovery, and overall cost-effectiveness as compared with the open approach. This video shows a laparoscopic live trans-abdominal right adrenalectomy.

關鍵字

Laparoscopic right adrenalectomy, transabdominal approach, intraoperative adhesion

媒體類型

手術影片

期間

24'20''

刊物

2011-11

普通的

最愛

Favorites Media

音訊

數位出版

WeBSurg.com, Nov 2011;11(11).
URL: http://www.websurg.com/doi-vd01en3441.htm

Difficult laparoscopic right adrenalectomy due to intraoperative adhesion

1. Case presentation and trocar placement 00'17''

This is the case of a 75-year-old man with a BMI of 32 and in his past medical history, he had an open cholecystectomy in 2006 and a radical prostatectomy in 2009. During the work-up for hypertension, the biology was the catecholamines were normal, the aldosterone was twice the baseline and the renin activity was also reduced. You see here the CT-scan of this patient with the right adrenal gland here just close to the liver, and on the different slices, this is the tumor precisely here, and we also see the vessels linking the vein here, linking the adrenal gland to the vena cava. In 3D, you can find the same patient. The different organs can be added. First, we will remove the skin to see the liver under the skin. We remove bones, this is the lateral view with this big vein connected to the gland. We also have here an accessory vein of the liver. It’s interesting to see it because this vein will be here during the procedure. It could be interesting to visualize that before the surgery. And we have a very small vein, perhaps not an adrenal vein that is close to the adrenal gland so there’s very certainly here a link in this area between the adrenal gland and the vena cava. As Luc Soler said, this is the case of a patient with a Conn’s adenoma. So the first part of the procedure was to free this adhesion but if you want, I can start to show you where we put the trocar. The patient is in a full lateral position, and as you see, the abdomen is going a little bit down. Here I have drawn the subcostal margin that you can see here with the xiphoid appendix and the umbilicus is there, a little lower because the patient is rotated down. That is the iliac crest and the patient is a little bit bent with the head down and leg down to increase the distance between the costal margin and the iliac crest. Four ports are placed. The first one is placed on the anterior axillary line. It is an open approach. It is a 10-12mm trocar. Then, on the mid-axillary line, we have a 10mm port, which is usually 5 to 7cm away from the first one, and a third operating port, again placed under direct control, 5cm behind port number 2, which is at the level of the 12th rib—see that was drawn here. These are the 3 operating ports. And one more port is a 5mm port placed close to the umbilicus because you need to put a liver retractor.

2. Liver retraction 03'28''

So internally, here you can see the liver retractor coming from the umbilical region and here you see this adhesion of the omentum that I have partially freed to give enough room to put the liver retractor inside. The retractor will be placed behind the right liver. It will play a fundamental role in exposing the operating space during the operation.

3. Vena cava identification 03'55''

Second landmark that we usually see--an interesting landmark in the open approach, it is the vena cava, but here in fact due to the adhesion, we will see this landmark a little bit later. When I have such dense adhesions, there are many possibilities to dissect. I very frequently use the hook, which can retract the tissues and grasp some small adhesions like that. The objective is to progressively remove the liver from the operative area. So I will go ahead freeing the lower part of the liver, and I’m looking for the first landmark of dissection, and this first landmark should be the vena cava. It is a little bit hidden here by this adhesion due to previous surgery. The vena cava will be located here. It is the first landmark we have to identify when we do a trans-abdominal approach, and that makes the approach to the right gland not difficult because we will always find this landmark. When this is done, the step that I have to perform now is to be able to lift more the right lobe of the liver. You know that during this surgery, the risk is to have bleeding, to have something that alters the quality of view. That’s why we like to work with this little peanut that makes possible the exposure of the tissues without grasping anything and avoiding tear of tissue. A second risk in this patient is to have a direct hepatic vein going from the liver directly to the vena cava. The direct veins from the liver to the vena cava, which are the accessory hepatic veins can also be at the origin of bleeding at the beginning of the surgical procedure, and probably I have here one of these accessory veins. At this level, for the moment, I will not cut it but if there is any problem of exposure, I will complete the dissection of this vein and free it. Now we are in quite a common and normal situation.

4. Dissection of inferor part of liver and peritoneal reflection 06'17''

Now the objective is to free the inferior part of the liver and the peritoneal reflection. This freeing will be done until a complete section of the triangular ligament, which will be the only way to lift up the liver and to completely open the adrenal space. The objective is really to remove the gland and its surrounding fat. I know that I have a nice dissection of the liver when I have a junction between the section of the triangular ligament and the opening of the peritoneal reflection below the liver. I need to complete the mobilization of the reflection line at this level, and here I’ll take the hook. Here again, it is the reflection line, which is open. Now the liver is free until this junction here behind and I will come back close to the major landmark, which is the adrenal gland. So the objective is to free the lateral side of the vena cava in order to identify the first landmark that we will try to find --the lateral side of the vena cava. Thanks to this position of the patient, who is in a lateral decubitus, the adrenal vein, which is usually behind the vena cava should be with the patient in this position, lateral to the vena cava. We know in 10% of the cases, we have an accessory vein. Where is this dangerous area of dissection? I’d say that in this case, it’s interesting because it is typically this vein that could be joining the adrenal vein, that could be very closer, and the second one is just over the main adrenal vein. And this is here in the angle of the liver and of the vena cava. So I will look a bit later at this place but somewhere here there is a risk to have this accessory vein, which exists in about 10 to 15% of cases. The objective for me is to free laterally the vena cava from down to up, and by doing this, I will have a free space as you see here. But I will also cross the main adrenal vein somewhere. We identify clearly the origin of the vein. It is over the level of the hepatic vein so it’s probably the main vein that was quite well-shown by Luc Soler. I have something here. I don’t know what it is here behind.

5. Main adrenal vein identification 09'21''

We have very well seen the dissection of the main adrenal vein. Why don’t you decide to control this vein first? At this level, as long as the dissection doesn’t make any problem, I like to complete the mobilization of the liver to have an exposure probably of the upper part of the gland. Now you’re right. Here I have completed the freeing of probably the internal part of the gland. Here you can see that the vena cava has been freed completely laterally, probably the internal border of the gland here, and here also I have the lateral side of the vena cava. I will show you an instrument that we always have on our table. It is a 10mm clamp, a white grasper, but in case of an emergency, you could do a lateral clamping of the vena cava. The second advantage of this clamp is that it is a real lateral clamp to go behind the vein and to make a control in exactly the same way you would do in open surgery. And here you see, we have almost 1cm of main adrenal vein and the objective is to clip it very early. It’s a very nice demonstration. I think your remark is very good to always have this kind of clamp, nearly a vascular clamp. And I remember more than 10 years ago our first injury to the vena cava during a demonstration in the UK, hopefully we have this instrument and we were able to control the vena cava immediately.

6. Adrenal vein cutting 11'22''

So here just to show that before cutting, I check the position of the clip to be sure that they take the whole vein. And as long as this is done, I will now cut the main adrenal vein. Usually I cut always half of it to be sure that there is a good control, no bleeding and when it is done, I complete the section just of the vein. The next objective of our dissection will be to find the arterial landmarks. Where are we looking for the three arteries? One is the medial artery. It usually originates directly from the aorta and should be located just below the dissection of the vein. A second artery, usually, which is identified as a superior artery, originates from a diaphragmatic artery, and will be identified at the upper place. So interestingly, there is something here: probably artery, and here you see that it is again a little atypical position of this vessel. And that is certainly the medial artery attached to some little tissue here. I’d like to avoid significant bleeding.

7. Medial artery identification 12'41''

The internal edge of the gland is seen here and I have here a tension again on some tissue. If you mobilize a little bit more the liver from the triangular ligament, and probably you can retract more also the posterior part of the liver, and you get better room for your scope. OK, that’s a good solution that I will keep. For the moment, I have a longer retraction of the liver. So my objective will be to free the internal border. If you agree, I will take a Ligasure®. That is the place of the internal artery. This place can be taken very safely. That is the inferior border and the upper pole can be done the same way. And here this little reflection line will be free and we go far away. So the internal part of the gland and upper part of the gland are free It takes the place of the artery and you see that we are completely free behind the gland, and we have no remaining tissue between the capsule and the posterior area. And now I will move to the inferior dissection. The gland is free laterally, posteriorly. Now we have to take the internal part of the gland.

8. Kidney upper pole identification 14'08''

So we will have to open the area here, which is the upper pole of the kidney. OK, here we have the exposure, which is well done laterally to the vena cava. Here we feel the upper pole of the kidney. So we will start to open the peritoneal reflection here and to look for the upper pole of the kidney to find the space between the kidney and the adrenal gland. Again the objective is to go behind the adrenal gland without having any need to grasp the gland. So I like to identify at this level the upper pole of the kidney, which allows to go behind the gland and then complete. Then I will use the Ligasure® in this fat, which is very efficient to control. That is very superficial in the fat. In this case, I have to adapt a little bit what I usually do. Usually when I go here in the dissection, I dissect a little bit lower until the identification of the renal vein. But you see that the anatomical aspect here is not exactly the one we have usually due to this adhesion here. I will open a little bit more here. I will just increase the quality of the exposure, and I will not cut anything significant. So now I have the answers to all the questions we had before. I have freed the second duodenum, that due to the adhesion here, was covering the field completely. That was the problem. So I have freed this. You see that we identify the second duodenum very well here. This has allowed me first of all to continue the dissection of the vena cava. Now I have found a medial pedicle. I have dissected down and as asked before by Dr. Giulianotti, here we have dissected down very low until the origin of the renal vein. This allowed us to see the little vein that was shown by Luc Soler, and he didn’t know whether or not it was a vein in the operative field. So as we have the angle between the vena cava and the renal vein, we know that we are down. On the opposite side, I have freed the posterior aspect of the gland identifying the upper pole of the kidney, and there were a lot of adhesions, and again very interestingly, by mobilizing the posterior pole of the gland, I have seen an upper renal artery that you can see here. That could be very easily cut if you dissect straight here, without identifying the upper pole of the kidney and the angle of the renal vein. And you see that a blind dissection here would have cut this renal artery. So the dissection plane is posterior to the gland here, preserving the renal artery. Here we have no tissue. There is certainly here the inferior pedicle and I will join the lateral border of the vena cava that is free. So my objective now is to continue to free the inferior edge of the gland preserving the renal artery that we have identified here. So if I mobilize the gland again posteriorly, here we identify the inferior horn of the gland, and again no manipulation of the gland. Posterior blunt dissection and here now as we are much lower than the renal vein, we can go behind the vena cava to complete the internal freeing of the gland. So I take again this place and I push posteriorly to be on the para-vertebral muscle. Again I take the little things that were bleeding here.

9. Adrenal gland mobilization 18'51''

Here you can see some posterior nodes, and I am otherwise on the muscle, probably some slightly vascularized tissue behind. But you see here very well. Here I am completely on the muscle so I really take out the whole fat, and now you see again that the posterior dissection is completed. The landmarks are correct: vena cava, inferior edge, a little vein is here, the artery is preserved there; and the gland is free posteriorly, just some blunt tissue behind in the fat behind the gland; Here’s the upper pole of the gland here, probably the last posterior attachment in the fat. You see that I never grasp the gland, I just retract it with a little peanut.

10. Specimen extraction 19'58''

The gland is free with its fat. Now we see very well the landmarks. That has to be identified. That is the accessory vein that was identified by Luc Soler. We have the internal part of the vena cava until the origin of the renal vein here, accessory vein identified by Luc, renal upper artery here well-preserved; the complete adrenal area is free, the upper pole of the kidney is identified, and we have the gland with all its surrounding fat here. That is the fat. So the area is clean, no blood, good landmarks. So we’re going to extract the gland now. We are going to put the gland in a bag. I will put the swab immediately with it. You see I’ve had a swab but there is no blood. Next step is just to bring the bag at the level of the skin. I’ll catch the stitch here. And now I’ll see how I have to enlarge the incision. I take the electrosurgical device and I’ll take the opportunity to use the whole incision, 5mm. I cut muscle on the opposite side. OK, it’s done. I will show you the specimen now. This is the typical adrenal gland. You see this round tumor located in the center. And here we have the three arms of the adrenal gland and the round tumor centrally, which is about 2cm in size.