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Laparoscopic retroperitoneal left adrenalectomy

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Laparoscopic retroperitoneal left adrenalectomy

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laparoscopic adrenalectomy,retroperitoneal approach

媒體類型

手術影片

期間

12'00''

刊物

2005-05

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WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-vd01en1795.htm

Laparoscopic retroperitoneal left adrenalectomy

1. Landmarks and patient positioning 00'14''

The head of the patient is here, the spine is here and the abdomen is here. The patient is in prone position, the operation is extra-peritoneal or retroperitoneal and all the incisions are below the 11th or 12th rib.

2. Trocar positioning 00'31''

Here I can feel the bone and the idea is to put the first trocar exactly to the periosteum of the 12th rib, go inside the retroperitoneum. Now the scissors are inside, so just on the tip of the 12th rib now. I put in my finger to create a little space and then I put in my second trocar. The rib is going this way, the adrenal is here, this means that now we put in a 10mm trocar at an angle of perhaps 30 degrees. The incision must be done here to put in the trocar in that direction so we can look at the adrenal. So it is very important that there is a distance between the rib and this incision. So I put in the trocar now just below the tip of the 12th rib. This is a 5mm trocar and my finger is on the other side. We take the third one and I put it in the incision that I have made in the beginning. We connect to the insufflator and I always do it at that point, we go up to 20. So the first step is to put the camera in the middle trocar, put it in here. This is a 30 degree camera, this means that you can turn around this part of the camera without turning this part. Very important in the beginning, we look from down to up. This is the beginning of the operation, you can see that you can see nothing. Now I can see my first instrument. This is the instrument which is here, on my left hand. This is the Gerota’s fascia.

3. Starting dissection of adrenal gland 02'28''

We are now outside of the retroperitoneum and we must open that fascia and this goes in that way. Only rupture and this is what we see in the very beginning: we see the retroperitoneal fat. If you look here, this is the spine. The patient is in the prone position, this means medially, on the right side, there must be the spine. In front of us it is the fat. You see that blue organ, that must be the spleen. The spleen is lateral, the spine is medial and we look at the peritoneum covering the spleen, we are on the left side. So now we push down a little bit of that fat. We switch the camera from the middle to medially. I now have two instruments to work with. Those are coming laterally. See that fat, this covers the adrenal, the adrenal is just behind here. We don’t have to look for it we know that it is there. Because we like to have a little more free space on that organ, I retract a little more of that fat now. Just push it downwards, you see what happens. You get a view of an organ, which is essential in adrenalectomy, it is a landmark. Again to demonstrate the situation, medially is the spine, in front of us we have the spleen and there is the kidney. We must start at that point, don’t care about the adrenal, it is always at the same place.

4. Superior pole of kidney 04'42''

You see I do some kind of blunt dissection now. It seems possible to me in this patient, sometimes it is rather difficult because of adhesions of the capsule of the kidney, perhaps due to infections in the past. We will start the operation at that point. We are freeing the upper pole. Now we are medially, but you know we are looking for the adrenal vein, we do some dissection of that fat. Again to demonstrate where we are: this is the upper pole of the kidney, here is some fat medially, this is the spine so I think we can dissect this now. Do you ever need a fourth trocar and if you do where would you put it? I think in the last 200 cases, we did not need a fourth trocar, if we need a fourth one it’s only for retraction of the kidney. There are fewer vessels that might be coming from the renal artery. This is the spleen, this is the kidney, this is the spine, and this is the adrenal, the back of the pancreas is behind that, so we are not able to see the pancreas just now. The adrenal is here and the upper pole of the kidney. Usually, you are able to cut these tissues with ultracision, sometimes in very large field chromocytomas there may be a risk because the vessels are more diffused and bigger. We are not so far of the adrenal vein, this is another very important step as you all know. This is the tail of the pancreas just behind that layer, you see there is something. Now we try to dissect the tissue region and we will find the vein now. There might be a small artery coming directly from the renal artery. This is an advantage of the retroperitoneal route, you are probably further away from that vessel than you are with transperitoneal. This vessel will come perhaps from here, the aorta is behind that, see the pulsations here? This is the aorta, the vessel will come here and enter here so we don’t touch it. First of all, you see that little artery. This is the lower pole of the adrenal gland and you see that if this pole goes down here, we will also be able to reach it by this approach. So now we cut the little vessels, which are entering the lower pole of the adrenal. As you know, the vein is not going at the lowest point. Again you can see the tissue of the adrenal, the lower pole, the fat around that vessel. We try the Ligasure now because of the fog. Here we have the spine, the aorta is just there behind the pulsations behind the muscles.

5. Adrenal vein 09'00''

Here is the spleen and the kidney is here. I take the clips, usually I take the absorbable clips. It is not necessary to preserve that vein. I now lift up the adrenal, push down the peritoneum on the other side. The tail of the pancreas is behind that. For the first time, we can see the tumour. We continue at that point because it is fixed there, so I cut this now, there is nothing perhaps a little artery but this does not matter. There is still the vein, and again I must point out if there is no fat around the adrenal, it is a simple thing to do that. This is not the tail of the pancreas, this is the stomach. You see now we are reaching the upper pole of the adrenal, it is here.

6. Superior pole of adrenal gland 10'45''

Again I respect that fascia which is in front of us, subtotally mobilized, there is a little fat lateral. I feel that there is more than one tumour. At the end, we have one little adhesion here. It is not a mistake to take out these glands if you have a predominant nodule as we can see here.

7. Extraction of specimen 11'20''

It will help the patient perhaps for a few years, perhaps for more but we don’t know. The Endo-catch is a very nice thing you know. I remove the gland now, I hope it comes out. There is nothing in that space, I don’t think we will put in any drainage. The kidney covered by a little fat, this was retracted in the beginning. The spine and the aorta and here we have the spleen. This is the end of the procedure. Thank you for your attention.