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Laparoscopic left adrenalectomy by retroperitoneal approach

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Laparoscopic   left   adrenalectomy   by   retroperitoneal   approach

作者群
J Bonjer
關鍵字
adrenal glands,left adrenalectomy,retroperitoneal,resection
媒體類型
期間
28'00''
刊物
2003-02
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Feb 2003;3(02).
URL: http://www.websurg.com/doi-vd01en1408e.htm

Laparoscopic   left   adrenalectomy   by   retroperitoneal   approach

1. Case presentation 00'04''
Our patient is a 54-year-old female with left upper quadrant pain, found to have a left incidentaloma. Colonoscopy was normal and her blood test showed no abnormalities. She had normal levels of adrenaline and noradrenaline in her serum and urine tests, and this was found to be a non-secreting tumour. You can see clearly the lesion in the CT-scan here in the left upper fossa. Here is the iliac crest and over here are the ribs, so this space is relatively small. It is important to correct the table as much as possible to make the skin in between the iliac crest and the ribs taut. This is the 12th rib over here and this is the 11th rib, we have made an incision of 1.5cm just below the tip of the 11th rib. Then we cut down to the fascia, we transect the fascia with cautery and then with the finger, we perforate the abdominal wall muscles. Right away, you can palpate the lower pole of the kidney, what you should be able to feel is the inside of the ribs, you have got to be able to lift up the ribs. Then we are going to introduce this balloon dissector, it is the same one we use for inguinal hernia repair and we’ll inflate the balloon under direct vision. We use a 10mm 0 degree scope; for the insertion of the dissecting balloon, you want to insert it towards the vertebral colon, not towards the peritoneal cavity because if you insert it like this, then you might perforate the peritoneum. Let’s put it in now. Now I insufflate the balloon under direct vision, the first landmark we can notice is this muscle, the quadratus lumborum, often known as the psoas muscle, even though that is not correct as the psoas muscle is in a more medial position. In patients with Cushing’s, you should be careful not to insufflate this balloon too many times because all the tissues in these patients are so fragile that you can easily rupture them. We then deflate the balloon, we insert a blunt trocar, you can inflate the balloon at the tip, we insert the balloon, and then we insufflate the retroperitoneal space. I insufflate to a pressure of 12mm Hg. I insert the second trocar, a 5mm posteriorly and not too low. I have inserted the second clamp, now I am looking upwards, what you can see here is a very thin, almost translucent greyish fascia; we call that the lateral coronal fascia. It extends from the quadratus lumborum muscle to the peritoneal sac. We are going to open that up in a minute and that will expose the fat around the kidney. Before we do that, we are going to insert 2 other trocars, which will be more medial and this is also an important and sometimes difficult step. We are looking from lateral to medial more or less, what we can see here are the muscle fibers of the anterior abdominal wall of the transverse abdominal muscle. It is important to stay very close to those muscles because if you go lower in here, you will make a hole in the peritoneal sac, which it is not a disaster but it will reduce your working space. The port is pushing down on the abdominal wall and you have to look really steep upwards to get in the right plane. We are still looking in a medial fashion, what we can see very clearly over here is this greyish structure, which is the peritoneal sac. This is how close the peritoneal sac is to the abdominal wall. That points out that you have to mobilize it very close to the abdominal wall. We hit a little vessel where we have inserted I think. After the insertion of the trocars, we are going to open the lateral coronal fascia down here. You can see that we can just sweep it away, look up a bit. We have opened the lateral coronal fascia; my assistant retracts the fascia with the fenestrated clamp. This is also the approach we use to clip endoleaks. What you see here is the kidney. I am not thinking about the adrenal, I am just thinking about the kidney. Now he is inside the lateral coronal fascia, the kidney is down on the bottom and the diaphragm is up above. And this is the quadratus lumborum, the muscle. The kidney is showing up and we were saying that it is very important to know where your lateral coronal fascia is, which is where the left grasper is. In this fatty space, it is also often very difficult to get going, in the beginning of the procedure, it can be sometimes frustrating. We feel that this is a very direct approach towards the adrenal. You don’t have to mobilize the spleen, or on the right sides of the liver, or retract the liver, which can be difficult when there is a steatotic liver. We will work on the image again. My conversion rate is about 5% and it was mostly at the beginning. That is beautiful exposure now, we can see the adrenal very nicely. As you can see, we don’t start out at the vessel, we start out at the periphery. Use indirect traction of course, never grasp the adrenal. Professor Marescaux, do you do virtual reconstruction in many types of surgeries, not just adrenal surgery, but hepatic or pancreatic surgery? You know that we have worked on this program since 1996, it was only for liver surgery to start with, but more and more we want to adapt it to other types of surgeries, adrenal reconstruction was the first or second one that we had done in the department but there are now 25 computer scientists, until last year there were only 3, very exciting for us. Trying to create a traction, counter-traction situation. I think we are going up to some of the vessels and upper pedicle there. He is not concerning himself with where the adrenal vein is at this time. We can see that edge of the adrenal gland developing nicely here. He’s gone laterally and now he’s around the superior pole and he’s coming down the medial side. What do you do if you do make a little hole in the peritoneal cavity? We sometimes insert an additional trocar to retract the peritoneal sac mechanically, but usually it is not necessary. You can see the lateral aspect very nicely and the posterior aspect too. Now we have dissected the lateral aspect, now we go inferiorly by gently pushing up the adrenal. Do you traditionally leave the vein dissection for the very end of the procedure? Yes, on both sides. Now here comes a vessel, I think it is the inferior adrenal artery. I am going to call it like that today. The surgeon’s left hand really is setting this up. I think it is better to use a gauze than irrigation and suction because it then becomes a soup and it is more difficult to discriminate the anatomical structures. One can get into more trouble going after that bleeding than doing what you are doing now? I think so, we are just going to compress it a little bit and then we will continue. The posterior approach has a size limit of about 5 or 6, the lateral retroperitoneal is about 6cm, I don’t think you can safely do bigger than that. The trans-abdominal approach would then amount to 15-16cm. Looks very nice and dry now from here. The tumour itself is pretty high so it is probably in the superior pole of the adrenal gland. Yes, you could see that on the CAT-scan, we suppose we should encounter here a normal adrenal gland, a normal rim. This looks like the vein to me. That looks very promising. It can be difficult not to run into the adrenal under the tumor, so I think we should stay in this plane. We can see the edge of the adrenal nicely here. This piece of fat is sitting in our way, it is blocking our view, so I will take it out. Adrenal veins on the left side are nearly always at the same point; this means that you always find a relatively long vein that is behind the fatty tissue that he is just preparing and there will always be this additional branch going up to the diaphragm, I have never seen a variation of this vein in the left side. On the right side, it may be very difficult as we said before, about 10% have abnormal veins going directly to the liver or a second vein going directly to the vena cava so we must be very careful on the right side, but on the left side, it is easy. What would you do if that renal vein had a leakage or a rupture? The answer is don’t do too much because you have a gas pressure of 12, perhaps increase the pressure a little bit and the central venous blood pressure is perhaps lower than 12 so there will not be any big bleeding in these situations. Take a gauze on it as he does and wait, in many cases there will not be a relevant problem. There were some branches sitting over the vein. Often, there is a smaller artery running parallel to the vein, the earlier branch was not the inferior adrenal, this should be it now. Are you able to see the inferior phrenic vein joining your left adrenal vein? I don’t see it now but often we do. I want to dissect a little bit behind it. Because of the length of the adrenal vein, it is not necessary to identify the renal vein in all cases. Now I think it is safe to clip. Now it is much easier to mobilize it. There still can be a superior branch from the phrenic artery so you should take care until the very end of the dissection and we will just put it in a bag and remove it.