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Importance of intraoperative identification of the vascular supply in a large (14cm) right pheochromocytoma

Laparoscopic adrenalectomy for large masses is a technically demanding procedure that should be undertaken by experienced laparoscopic surgeons familiar with retroperitoneal anatomy. In case of very large tumors, a primary vascular approach must prevail over any other types of dissection. This video shows the case of a patient presenting with a voluminous non-secreting adrenal tumor (with a diameter of 14cm) in which a primary laparoscopic approach is decided upon as performed conventionally.

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Importance of intraoperative identification of the vascular supply in a large (14cm) right pheochromocytoma

作者群

D Mutter, L Soler, J Marescaux

摘要

Laparoscopic adrenalectomy for large masses is a technically demanding procedure that should be undertaken by experienced laparoscopic surgeons familiar with retroperitoneal anatomy. In case of very large tumors, a primary vascular approach must prevail over any other types of dissection. This video shows the case of a patient presenting with a voluminous non-secreting adrenal tumor (with a diameter of 14cm) in which a primary laparoscopic approach is decided upon as performed conventionally.

關鍵字

intraoperative identification, vascular supply, large right pheochromocytoma

媒體類型

手術影片

期間

19'00''

刊物

2009-11

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Nov 2009;9(11).
URL: http://www.websurg.com/doi-vd01en2772.htm

Importance of intraoperative identification of the vascular supply in a large (14cm) right pheochromocytoma

1. Introduction 00'12''

The management of voluminous adrenal tumors may be anticipated provided the principles established for this approach are respected. In case of very large tumors, a primary vascular approach must prevail over any other types of dissection.

2. Clinical case 00'34''

We report the case of a patient presenting with a voluminous non-secreting adrenal tumor (with a diameter of 14cm). A primary laparoscopic approach is decided upon as performed conventionally.

3. Liver mobilization 00'47''

The principles established for this surgery require that the liver must be freed first in order to be lifted up and retracted away from the adrenal tumor. Because of the volume of the gland, as can be seen throughout the dissection, the whole of the planes are distended. Dissection must be carried out in order to identify the basic anatomical structures.

4. Vena cava identification 01'20''

Once the liver has been mobilized, the inferior vena cava must be identified. Once again, the vena cava is the internal anatomical landmark that should be identified absolutely in order to achieve a safe dissection of the gland. The gland is usually exposed using a small peanut swab mounted on a dissecting forceps. This helps to achieve an atraumatic retraction of the gland. Because of the tumor’s size and of its solid nature, its mobilization remains uneasy. The peritoneum is then progressively opened in order to distend the cellular adipose structures in contact to the gland.

5. Vena cava dissection 02'05''

Dissection of the inferior vena cava is continued from caudad to cephalad. Anatomical alterations lead us to first identify direct hepatic veins. These are progressively controlled in a stepwise fashion in order to lift up the liver at a sufficient distance and to identify the superior part of this voluminous adrenal gland. The control of its vascular elements remains important due to the risk of bleeding in case of sudden traction on the liver. The preparation of the inferior vena cava is carried out on its right and superior border. As the tissues gradually tighten all around the gland, they will be coagulated and divided in turn.

6. Identification of direct hepatic veins 03'00''

The bipolar coagulation is beneficial in that it allows the coagulation of small direct veins within the liver. Here we can see that the identification of the ideal plane between the adrenal gland and the liver is uneasy. Dissection is pursued to the right, then to the left. Dissection to the left leads us to identify other direct hepatic veins, which are also controlled by clip applications and ligated. At this moment, the progressive and delicate traction on the liver using the xiphoid retractor contributes to achieve tension on the cellular adipose elements along the right border of the vena cava. The objective is to identify the main adrenal vein. The dissection above the gland is difficult as it measures 14cm. Likewise the vena cava is compressed by the tumor. However, a delicate traction on the gland helps to identify a dissection plane.

7. 3D reconstruction 04'27''

As can be seen in this 3D reconstruction, the adrenal vein is not identified immediately. The vena cava is greatly retracted by the tumor larger than the kidney itself. The tumor lies on the superior pole of the kidney. Dissection is continued on the superior, then lateral border of the vena cava until the main adrenal vein is identified. In such difficult cases, we prefer to use a right-angled clamp. This helps to pass posterior to this adrenal vein, which measures about 1cm in diameter. Its voluminous size does not allow to place clips directly. We then use an artifact, which consists in passing a ligature posterior to this vein. The objective of the ligature is not only to ligate if necessary, but also and above all to diminish the vein’s diameter thanks to a slight traction in order to control it by clips. Here we can see that clips allow to safely control this vein that will then be divided. This maneuver prevents any wounding of the vena cava and allows for a safe dissection of the other vascular structures. Immediately our attention turns posterior to the vena cava but because of the tumor’s size, access to the posterior plane is impossible. Then the dissection of every plane around this gland is continued in a stepwise manner, first at the subhepatic level, using either a coagulating hook or an ultrasonic dissector.

8. Inferior pole dissection 06'27''

Since the gland is mobilized, its inferior pole may be dissected in contact to the renal vein. There is a potential risk of wounding the renal pedicle at this level because of the alterations of anatomical landmarks related to the gland’s size. The freeing of cellular adipose structures at the level of the medial and superior border of the gland is carried out distal from the renal pedicle using an ultrasonic dissector. This instrument allows for a safe dissection of the cellular adipose structures without any bleeding.

9. Peritoneum opening 07'08''

The peritoneum is immediately and completely opened. Then an in-depth dissection is achieved in order to identify the renal capsule. In case of tumor, this helps us to rule out that the renal capsule has not been invaded. As a reminder, the tumor has not yet revealed its true nature. Therefore, in case of malignant tumor, it is essential not to rupture the capsule.

10. Renal capsule dissection 07'44''

The ultrasonic dissection is continued along the renal capsule. This achieves an almost ideal dissection plane. The present objective is to identify the vascular pedicle of the kidney as well as the inferior vascular pedicle of the adrenal gland. As a result, the dissection is carried out in a stepwise fashion. Any ligation performed blindly owing to the anatomical alterations would bring about a risk of injuring or cutting the renal artery. A first artery with a diameter of about 3 to 4mm is identified. This artery will not be controlled until we are sure of its orientation. To do so, the dissection is pursued on each side of the artery. In particular, the superior pole of the kidney will be dissected in order to obtain a cleavage plane between the tumor and the kidney’s superior pole. This will help to place tension on the adrenal tumor along with tension on its vascular pedicles. The inversion of instruments in the operator’s right and left hand is sometimes necessary in order to continue the dissection in planes that are difficult to access.

11. Posterior vein division 09'01''

A posterior vein classically found in all dissections is still identified at this level. It is controlled by ultrasonic coagulation. It can also be controlled by clip or bipolar cautery. The dissection of the kidney’s superior pole is complete. However, we can observe a very small parenchymal lesion towards the kidney. No capsular rupture may be observed at the level of the adrenal gland, which is never manipulated but always retracted with a peanut swab. Then our attention turns to the angle formed by the kidney’s superior pole, by this artery, which has not identified with complete certainty, and by the vena cava visible to the right of the screen. Before being divided, this artery is dissected over a sufficient length to be sure of where it heads to.

12. Renal vein dissection 10'07''

The vessels of the renal pedicle are beginning to be identified more precisely, the renal vein is dissected along 3cm, it is then clear that the renal artery must be situated above that renal vein.

13. Renal artery identification 10'19''

The dissection, using the coagulating hook first, then with the ultrasonic dissector, will allow to identify the totality of the renal artery above and posterior to the tumor. This allows us to identify the inferior adrenal artery. The artery that was first thought to be an adrenal artery is in fact a pedicular branch of the renal hilum. The anatomy’s exposure becomes much clearer and precise at that moment, and the whole of the gland’s inferior pole begins to be identified. The renal artery is then perfectly identified with its division branches: superior polar, inferior polar, and an inferior branch. This dissection is particularly interesting at that moment as it allows to perform a posterior dissection at the level of the tumor. Its gradual mobilization will allow to gradually push it away from the vena cava’s plane in order to check its posterior and inferior attachments. Due to the doubts concerning the nature of the adrenal tumor, we prefer to remove the whole of the peri-adrenal capsule. The dissection is then carried on to the cellular adipose tissue superiorly and posteriorly. As we routinely perform, the whole adrenal bed will be removed in a single bloc while avoiding a rupture of the adrenal capsule and with a control of all the vascular elements. The gland’s inferior and external portion being free, we return to the angle formed by the renal pedicle and the gland that will be more easily lifted thanks to its mobilisation.

14. Control of inferior adrenal pedicle 12'58''

An inferior adrenal pedicle is controlled by applying clips. The aim is to identify the medial adrenal pedicle directly at the level of its inferior border. The incomplete identification of a small arterial branch is immediately followed by a hemorrhage requiring the application of additional clips. Here again, the step by step dissection allows to apply the clips securely with a perfect identification of the renal artery and vein. Clip application, followed by a careful suction of the dissected elements, are essential. Adrenal tissue is identified here, which is the reason why the dissection will be carried out 1cm posteriorly in order to preserve the adrenal gland. The ultrasonic dissection completes the freeing of these cellular adipose elements. The gland’s inferior dihedral plane being completely dissected, the dissection continues from caudad to cephalad along the inferior vena cava. This will allow to gradually identify the medial adrenal vascular pedicle. Occasionally, using bipolar coagulation can ensure the hemostasis of areas that have not been completely controlled.

15. Control of medial adrenal artery 14'51''

The medial adrenal artery is identified and controlled again by applying a clip. The dissection is completed with an ultrasonic dissector to ensure the hemostasis on both sides of the division line. The posterior and internal freeing of this adrenal tumor can continue in a step by step fashion. A few lymphatic and pedicular elements are controlled by applying clips. It is essential to have a bloodless dissection to preserve the adrenal capsule throughout the dissection. Here we can see that the dissection is clearly carried out away from the adrenal capsule. The dissection was continued from caudally to cranially along the vena cava.

16. Completion of adrenal gland freeing 15'56''

All of the adrenal border is free, its posterior and left parts are completely freed; only the adhesions between the liver’s inferior border and the gland’s superior part will need to be brought down. This dissection will be particularly fastidious due to the gland’s size and because it is not possible to place the ports above the tumor. Indeed, the ports are already placed along the costal margin; it is not possible to introduce ports between the ribs. However, the entire mobilization that was performed at the gland’s medial and lateral part allows again to exert sufficient traction on the tissues to perform a gradual freeing at the liver’s inferior border. This adhesional area is free from vessels but the exposure remains difficult at that level. The dissection at the liver’s inferior border is finished with the help of a peanut swab and with the suction drain. The liver’s inferior border is perfectly identified, along with the gland’s attachments. The latter is then completely mobilized; a subcostal incision restricted to the gland’s size is performed to extract it. The extraction is performed after the introduction of a safety bag. The gland measured over 14cm long and the histological examination reveals that it is a pheochromocytoma.