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Laparoscopic adrenalectomy: typical vascular anatomy and 3 major venous variations

The laparoscopic approach to adrenalectomy is based on the identification of vascular landmarks. We present a typical case of right adrenalectomy using 4 ports: one epigastric port to retract the liver, three subcostal ports to explore and dissect the adrenal fossa. This is a very interesting video in which we disclose vascular anomalies. A very good exposure of the operative field and the absence of bleeding during the procedure contribute to the perfect identification of these anatomical anomalies.

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Laparoscopic adrenalectomy: typical vascular anatomy and 3 major venous variations

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D Mutter, F Costantino, J Marescaux

摘要

The laparoscopic approach to adrenalectomy is based on the identification of vascular landmarks. We present a typical case of right adrenalectomy using 4 ports: one epigastric port to retract the liver, three subcostal ports to explore and dissect the adrenal fossa. This is a very interesting video in which we disclose vascular anomalies. A very good exposure of the operative field and the absence of bleeding during the procedure contribute to the perfect identification of these anatomical anomalies.

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tips and tricks

關鍵字

Laparoscopic adrenalectomy, typical vascular anatomy, 3 major venous variations

媒體類型

手術影片

期間

08'36''

刊物

2009-10

普通的

最愛

Favorites Media

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副標題

數位出版

WeBSurg.com, Oct 2009;9(10).
URL: http://www.websurg.com/doi-vd01en2673.htm

Laparoscopic adrenalectomy: typical vascular anatomy and 3 major venous variations

1. Introduction 00'13''

The laparoscopic approach to adrenalectomy is based on the identification of vascular landmarks. We present a typical case of right adrenalectomy using 4 ports: one epigastric port to retract the liver, three subcostal ports to explore and dissect the adrenal fossa.

2. Liver mobilization 00'30''

Dissection is started conventionally by mobilizing the right liver. Since the adrenal gland is positioned underneath the liver, such mobilization helps to lift the liver upward and approach the adrenal fossa safely. Dissection of the lower border of the liver should be carried out until complete dissection of the liver’s triangular ligament. Only this complete dissection allows to lift the liver upward satisfactorily.

3. Identification of the inferior vena cava 01'00''

The first anatomical landmark used is the inferior vena cava, which is freed at the liver’s lower pole.

4. Dissection and division of the main adrenal vein 01'09''

Then its right border is dissected in order to approach the main adrenal vein from caudad to cephalad. The main adrenal vein should be dissected over a length of 10 to 20mm in order to ideally apply vascular clips safely. Dissection is merely carried out using a coagulating hook that enables the electrocautery of small vascular elements surrounding the vein. Such a painstaking dissection allows for safe clip application under visual control. Usually two clips are placed on the vena cava side and one clip on the adrenal gland side. Division of this first vascular element allows to retract the gland away from the inferior vena cava, hence permitting further identification of vascular arterial landmarks.

5. Identification of the middle adrenal artery 02'24''

The first arterial landmark is situated posterior to the main adrenal vein. This is the middle adrenal artery directly originating from the aorta. It is always present. It is also controlled either by electrosurgery or by clip application.

6. Division of the middle adrenal artery 02'43''

Its division allows to increase the distance between the vena cava and the adrenal gland.

7. Identification of a duplication of the main adrenal vein 03'00''

A first vascular abnormality is identified in this patient. Indeed, a duplication of the main adrenal vein is found. A second vein, well visible at this level, is identified upward to the first main adrenal vein. It is crucial to know about the existence of this abnormality since an excessive traction on the gland before control of this vascular element might cause a tearing of the vena cava. Such a lateral tear would be difficult to control given its localization.

8. Freeing the superior pole 03'45''

The following step of the adrenal gland dissection is the total freeing of its superior pole. This maneuver is carried out progressively distal from the vena cava safely. Usually, a single vascular element should be searched for: it is the superior arterial pedicle.

9. Dissection and division of the superior vascular pedicle 04'08''

This is achieved by progressive freeing of the adhesions between the upper pole of the gland and the liver. However, in some cases, in approximately 5 to 10% of patients, and as can be seen here, an adrenal vein draining directly into the liver is present. Its dissection is particularly difficult since the liver cannot be mobilized cranially. Consequently, the pedicle should be dissected sufficiently in order to apply clips; if not, there is a risk of either rupture of the gland or bleeding. In the present case, the use of curved forceps can be particularly useful in order to find the posterior path safely. This commonly induces a traction on the liver’s capsule with a small bleeding. Here again, this vascular pedicle should be absolutely controlled before dividing it. In the opposite case, there would be a risk of liver parenchyma bleeding that would be once again particularly difficult to control. Clip application also helps to control that the entire adrenal parenchyma has been resected in its whole. Normal anatomy can then be searched for. Freeing and progressive dissection of the attachments of the lower border of the liver is continued from left to right. Posterior dissection is extended up to the diaphragm until identification of the superior arterial pedicle originating from the inferior diaphragmatic artery. Here again, it can be controlled using either monopolar or bipolar electrocautery or again by clip application. In this patient presenting with a very thin artery, repetitive coagulation ensures a safe dissection. The adrenal fossa is freed almost entirely. The inferior pedicle remains to be identified. Usually in normal anatomy, the only element to be found at the inferior pole of the gland is the inferior adrenal artery originating from the renal artery.

10. Division of the inferior pedicular artery 07'02''

Here this inferior pedicular artery is controlled with bipolar cautery and with clips. It will contribute to the complete freeing of the gland, hence removing it away from the kidney.

11. Identification and division of an accessory adrenal vein 07'14''

Here again, a vascular anomaly can be encountered. It is an accessory adrenal vein draining directly into the renal vein. As can be seen here, mobilization and tearing off of this vein could lead to major bleeding associated with a potential injury to the renal vein. Here again, the dissection of the superior border of the renal vein is mandatory to make sure that there are no veins left that would drain directly into the renal vein. Once the inferior pole has been totally freed, the gland can be completely freed. There is usually no major vascular element at the superior portion of the kidney and at the right lateral part of the gland. Since dissection of the entire superior pole has been carried out, the few remaining adhesions can be freed by either monopolar or bipolar cautery or using the Ligasure device.

12. Removal of the adrenal gland 08'10''

Once the gland has been totally freed of its attachments, it will be retrieved from the abdominal cavity after placement into an extraction bag. A very good exposure of the operative field and the absence of bleeding during the procedure contribute to the perfect identification of all these anatomical anomalies.