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Laparoscopic retroperitoneal right adrenalectomy in an obese patient

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Laparoscopic retroperitoneal right adrenalectomy in an obese patient

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手術影片

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2005-05

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WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-vd01en1798.htm

Laparoscopic retroperitoneal right adrenalectomy in an obese patient

1. Landmarks and patient positioning 00'11''

We are on the right side, so this means that the head of the patient is here, the spine is here, I think this should be the region of the 12th rib but there is a lot of fat so it’s difficult to identify. Her legs are going down here, so now we start at the tip of the 12th rib that I am trying to identify. I’m trying to find the bone and I think that now my finger tip has reached some bone.

2. Trocar positioning 00'35''

You can see that it is rather deep, my finger is well inside. I put in the next trocar. I reach my finger now but I put it away because of the automatic trocar, I put in the next trocar on the other side. This might be the lower side of the 12th rib. The incision must be made here. I must now switch and put in the other finger. I’m trying to place my trocar in the ideal space. The problem with this patient is that she is fat, which means that the 12th rib is very deep, on the other side it’s close to the iliac crest. We put the camera in the middle port; the first view is the Gerota’s fascia. The first idea is to find that instrument.

3. Retroperitoneal dissection 01'30''

Very thin Gerota’s fascia, I can rupture it in that way. This is the fat we are looking for, the retroperitoneal fat and the 12th rib is rather deep. Now we see the fat but we cannot see anything else. This is something that I like to see, the peritoneum. Here again is the spine, the peritoneum covering the right lobe of the liver. Don’t destroy that layer, it is not necessary. Because the patient is so fat, to have a nice operation we increase the pressure to 24. You see what happens, I didn’t move the camera; the space is increasing. Now we go up to 28 and now we can see something. The space where we have to work, this is the spine but we don’t have the pulsation here, perhaps only very little there, the aorta is a little further away. Now we move to the other side. You can see the peritoneum covering the right lobe. You see the fat is like liquid, you touch it and it breaks. The first step is to remove a bit of the fat around the kidney, so that we don’t have so much fat around. It’s covered by a lot of fatty tissues as you can see, we know from the CT-scan that the patient has a kidney on the right side.

4. Superior pole of kidney 03'30''

Now you see, this might be the upper pole of the kidney and again I try to push the fat down and as you can see it breaks down very easily.

5. Starting the dissection of adrenal gland 03'40''

Don’t worry about these vessels. Sometimes in patients with this Cushing’s disease, or Cushing’s adenoma, it is possible to remove that fat with suction. Here we have the upper pole of the kidney, it is pushed down a little bit and we know from the CT-scan that the tumor lies directly on the vena cava. This means that if the upper pole is here, the tumor begins here. There is no additional adrenal tissue, inferiorly,the tumor. Medial, caudal, lateral. The tumor is behind that, this is the tumor. Now I will dissect those little vessels. Perhaps these are the inferior adrenal vessels just coming from the aorta behind that layer. Now we take the Ligasure. Now you see the upper pole of the kidney is here, here is some more of these vessels, I’ll just cut them now. I go a little lateral and cut this too, there is nothing, only fat. We are going a little laterally, again we are trying to dissect this region. This is the case where everything you touch will bleed. See that lovely blue structure, this is called the vena cava. You cannot dissect all the tissue that is behind the vena cava. There are crossing little arteries perhaps coming from the renal artery. Then we go a little lateral, but the first step now is to dissect the posterior part of the vena cava. If you increase the pressure in the abdominal cavity, you get problems. But you don’t get these same problems via the retroperitoneal approach. Now I am going medially, this is the tumor, the spine again. As you can see, I am still trying to dissect from the vena cava and everybody knows that in a few minutes we will see the vein. This approach is also nice because it is not a problem to find any tumors situated behind the vena cava. You know the typical pheochromocytoma right adrenal tumors are placed behind the vena cava. We go a little bit lateral and try to dissect that fat here. You see again, this is the peritoneum, it is typical to see that vein which I am just dissecting, it’s always there coming from the lateral, but in this patient I will not try to a precise dissection. CO2 now is 52. This is the fat that I dissect now, it’s from the region of the adrenal coming down to the region of the kidney. In order to get a clear situation, I cut this now. This is adrenal tissue, the tumor is down there, the vena cava is just there, the adrenal vein will be there. Now we try to dissect that. You see again the attraction of a 30° camera, it may show you things that you would never expect. Now we know where the vein is, if we would like to dissect the vein it would be possible, but first I would like to do a little more dissection of the tissue around. This is the upper pole of the adrenal. There is the peritoneum, the right lobe of the liver behind, the spine and the fat around the upper pole of the kidney is here, so the tumor is in front of us. I try to dissect that tissue, see you don’t have problems in finding layers. Again this is the peritoneum, you can see this is the adrenal from behind, the upper pole of the adrenal will be there. Now we go to the real upper pole of the adrenal, it is over here. You see the peritoneum is behind, seems to be a layer if you lift it up a little. We cut it here, we decrease our pressure now to 20.

6. Adrenal vein 09'16''

So, this is the adrenal vein, I think now we should take the clip applier. Now we dissected that vein, so you can see there are the clips, there is the vena cava and now we remove the tumor.

7. Vena cava 09'42''

How often do you drain? I drain in those cases where there is so much bleeding that was obvious due to the tissue, perhaps less than 20% of cases.

8. Extraction of specimen 09'59''

Now you have seen that we can reduce the pressure again to 20. Here is a final view.