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Laparoscopic left adrenalectomy: retroperitoneal approach

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Laparoscopic   left   adrenalectomy:   retroperitoneal   approach

作者群
J Bonjer
關鍵字
adrenalectomy,operation,adrenal glands,resection
媒體類型
期間
14'00''
刊物
2005-09
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Sept 2005;5(09).
URL: http://www.websurg.com/doi-vd01en1177e.htm

Laparoscopic   left   adrenalectomy:   retroperitoneal   approach

1. Case presentation 00'36''
The positioning of the patient is of utmost importance in this approach. This patient has a left adrenal tumor. We’ve put the patient on the right side so there’s a right lateral decubitus position. We’ve corrected the table as much as possible to open up the space in between the iliac crest and the ribs. You can see here a view from the side. We’ll move to a view from the front. We’ve indicated the ribs and you can also see the lower midline incision that has been made for the cystectomy and reconstruction. If we now go to the patient, this is the iliac crest, the 11th rib and the 12th rib, 10th and so on. We’ve just made an incision just caudally to the tip of the 11th rib so there’s a relatively small space in between the ribs and iliac crest but usually it’s not a problem and it’s no big deal today. We‘ve made just a 1.5cm incision inside the fascia and then we perforate or penetrate with one finger the muscular wall. With the tip of my finger, I’m below the ribs. You can see me lifting up the thoracic cage and when I’m down here, I can palpate the lower pole of the kidney. This is important that you penetrate the muscles and don’t end up in the subcutaneous space. We free up the space a little bit on the posterior side and I try not to go to the ventral side because I don’t want to perforate the peritoneal sac. This is the 1st step. The 2nd step will be the insertion of the balloon dissector, which you can see here. And now we’re going to insert this balloon and again orientate it posteriorly to the back of the patient. Don’t put it in too far as it’s not necessary and then we insert the scope (we start by using a zero degree scope). I’m slowly insufflating the balloon. It might become depressed now because in the beginning you don’t recognize anything. The 1st landmark we’re going to look for is the quadratus lumborum, which will be visible in a few seconds. It is over here. This is the muscle. You can see nicely the fatty tissue being pushed away by the balloon. Now we’re looking upward and this is all muscle down here. The quadratus lumborum is often called the psoas muscle, which is more over here. Now we take the balloon out. So we’re desufflating the retroperitoneal space. If you put your finger in now, the space is big. Now we insert this trocar, which is like a Hasson’s trocar. We can insufflate the balloon at the tip and this can move up and down and the abdominal wall is sitting over there like my fingers and it’s locked tight. There’s something particular with the extraperitoneal space. You have more fogging of your laparoscope in the extraperitoneal space than in the intraperitoneal space. What people have against this approach is that the anatomy is unclear. We’re now pushing on the posterior abdominal wall and we’re going to make a 5mm incision of sufficient space for your first trocar. Always remember not to put your trocars too closely together because it will end up in sword fighting and we don’t want that. We are going to insert a 5mm with a grip on it and we’re going to orientate it towards the location of the adrenal. There it comes and we put a grip on the trocar because just like an inguinal hernia surgery, trocars tend to fall out. Over here, this is the quadratus lumborum and this is the lateral abdominal wall; this is fat sitting around the kidney and you can see here a very thin translucent grey fascia. This fascia has caught the lateral coronal fascia that extends from the muscle over here. That is the quadratus lumborum extending to the peritoneal sac. We’re first going to mobilize the peritoneal sac; after that, we’re going to open this fascia and that will expose the kidney with the fat surrounding it. Now I’m moving the camera in a medial fashion. The trick is to be as close as possible to the muscular layer of the abdominal wall. What you can see here is the transverse course of the transverse abdominal muscles. We’re very close to the muscles. We’re mobilizing the peritoneal sac and in a few seconds, you will see the peritoneum. This is the peritoneal sac so we’re in between the peritoneal sac and the abdominal wall. Now I want to put my 5mm trocar over here. I just want to have enough space in between all trocars and I’m going to put 2 like my 2nd and 3rd fingers over here. This is more than enough space. The next step is that we’re going to open the peritoneal sac. We mobilize the peritoneal sac and I’ll go and open the lateral coronal fascia. This fascia is very thin here. We retract the lateral coronal fascia. We try to elevate the lateral coronal fascia. There’s quite a bit of fat. We first want to see the kidney. This is the kidney over here and this is the first part of the operation is just to remove fat. Sometimes it turns into some kind of plastic surgery. I’m working my way to the upper pole of the kidney and then I’m trying to free up the upper pole. I’m not thinking about the adrenal at this point. We don’t get a big enough space. I saw the adrenal over here. We freed up the superior pole of the kidney now and eased away a little bit of fat. There’s a little bleeding but it’s not problematic. I’m now pushing down the upper pole of the kidney. This is the pancreatic tail. We’ll move on a little bit with the zero degree scope and then we’ll go to the 30 degree. It’s always a bit difficult to get a start on the lateral side. This is all cleared out. This is all muscle. It’s important to clear out all the fat around the superior pole. And then, you’ll find the adrenal glands quite easily usually. Here’s a small artery. You can push on the kidney. And this is the adrenal vein. Now we move on to the medial side. You can see the adrenals coming up more. I’m trying to be as delicate as possible not to grasp too much. One of the most difficult things of adrenal surgery is retraction of the adrenal. Conversion rate is 4%. We had to convert all paragangliomas. This is a branch from the diaphragmatic vein.