Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, dissection, ligation of the veins, ligation of the arteries, end of dissection/extraction.
Consequently, this operating technique is well standardized for the management of this condition.
Since then, this approach has become the gold standard for benign disorders, as it offers several advantages:
- a minimally-invasive approach to the procedure (which facilitates it);
- a magnified view of the operative field;
- improved control of the vascular pedicles, particularly in obese patients;
- minimal postoperative discomfort due to the absence of large surgical wounds;
- reduced wound morbidity;
- reduced hospital stay.
- Small or non-secreting tumors are the best indication. These are:
- Conn’s tumor
- Cushing’s tumors
- Small virilizing and feminizing tumors should be approached cautiously. They are simple adenomas in most cases but the secretion can be the consequence of an adrenocortical cancer in about 30% of the cases.
- Incidentaloma with a size superior to 3 or 4cm (European and American references).
Bilateral tumors are a relative indication considering the overall operative time necessary to perform such a procedure.
- surgical history (major risks of adhesions making the transperitoneal approach impossible),
- surgical history of the kidney or liver (risky dissections). It is usually recommended to insert an optical trocar and to explore the adrenal region to make an optimal decision.
Adrenal gland related:
- large gland (from 8 to 10cm); The indication regarding the size of the gland is a quickly evolving data. When the limit was set to 8cm in 1995, the laparoscopic approach for tumors up to 14-15cm is accepted. In these large tumors, the dissection can be started by a laparoscopic approach that should be converted into an open approach in case of difficulties, difficult landmarks identification or risk of capsular rupture of the gland.
- problem of carcinoma: The problem of laparoscopic resection for malignant tumors remains controversial. In fact, limited data exists in the literature (Kebebew E et al., Arch Surg, 2002). However, the most recent references consider that laparoscopic approach in patients with suspected adrenal metastases can be achieved by a laparoscopic approach. In the same way, laparoscopic adrenalectomy for adrenal cancer is not systematically a contraindication.
However, it is well demonstrated that laparoscopic adrenalectomy for clinically unsuspected adrenocortical cancer is associated with a high recurrence rate probably due to the aggressivity of this lesion, but perhaps also accidental rupture of the capsula of the gland in hazardous dissection.
- intracranial hypertension and coagulation disorders are common contraindications in laparoscopic procedures.
- age, obesity, and compromised cardiac or respiratory function are no longer considered contraindications. Furthermore, these high-risk patients may benefit more than others from parietal wall and musculature preservation in the postoperative course.
Since the work of Meurisse et al. (1995) and Fernandez-Cruz et al. (1996), pheochromocytoma of the adrenal gland is no longer considered a contraindication to laparoscopic resection. However, appropriate preparation using alpha followed by beta-receptor blockade, or alternatively by calcium channel blockers, is highly recommended.
A cushion is placed under the contralateral lumbar fossa, which opens the operative field, thereby facilitating trocar placement.
2 + 3. Two assistants stand on the other side of the patient.
Two video monitors are used.
2. Anesthetic equipment
3. Laparoscopic unit
5. Electrocautery/ultrasonic scalpel
6. Instrument table
For optimal safety conditions, the operating room should be ergonomic, allowing ample space for the laparoscopic and anesthetic equipment.
Four trocars are usually required.
The position of the trocars may vary with the patient's body habitus.
A 30° laparoscope may be necessary, especially:
- in obese patients,
- in case of large tumors.
However, all of the instruments illustrated may be used.
Our operative strategy is based on complete isolation of the adrenal gland without clearly identifying it beforehand.
The key to the procedure’s success is to begin with dissection of the lienophrenic ligament using a dissecting hook. This dissection is carried out cephalad till one can visualize the greater curvature of the stomach and the left crus.
This allows for the entire mobilization of the spleen, which falls away from the operative field to the right, along with the pancreatic tail. It is no longer necessary to exert any medial traction on the spleen.
The left splenic flexure is not dissected, even if it is necessary to free a few parietal adhesions for the introduction of the external trocar.
This is achieved by dividing the lienophrenicligament.
The lateral decubitus position is used to expose the lienophrenic ligament.
The posterior surface of the spleen is dissected first, followed by that of the pancreas. The medial reflection of the spleen and pancreas exposes the renal vein and the main adrenal vein.
Dissection of the splenic vein is pursued for at least 5 or 7 cm on the posterior surface of the pancreas.
It is then dissected on its superior aspect until the main adrenal vein is exposed.
This reveals its convergence with an inferior phrenic vein.
These are for a left adrenalectomy:
- splenic injury;
- pancreatic injury;
- vascular anatomy confusion, especially between the main adrenal vein and the renal vein;
- division of a polar renal artery;
- rupture of the capsula of the gland;
- injury of the diaphragm.
Complications linked to the pathology of the gland will not be specifically detailed as they are not related to the laparoscopic approach; e.g., hypertension during surgery for pheochromocytoma, carcinosis linked to surgery for adrenocortical carcinoma.
2. Accessory adrenal vein
Once identified, it is dissected from the aorta in the fatty tissue, clipped, and divided.
The superior adrenal artery, which originates from an inferior phrenic artery, is identified at the upper part of the gland. It is dissected, clipped, and divided. At this point, the upper part of the gland is entirely freed from the diaphragm.
Cephalad retraction of the gland using a peanut swab is again necessary at this point of the procedure. This facilitates the search for the inferior adrenal pedicle (1).
This pedicle originates from the renal artery. It is located on the inferior posterior surface of the gland and is often composed of 2 or 3 vascular rami. These are individually dissected using a hook, then clipped and divided.
At this point in the procedure, the gland is totally freed from the kidney.
The few attachments located between the inferior lateral aspect of the gland and the upper part of the kidney are carefully dissected using either a monopolar or bipolar coagulating hook.
The extraction itself is performed through a trocar opening, which can be slightly enlarged depending on the individual case.
All port sides over 5 mm are closed by intra-fascial sutures and subcutaneous sutures close the port incisions.
- liquid intake resumes the night of the procedure.
- normal diet resumes on the first postoperative day.
- the patient may leave the hospital on POD2 or POD3.
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