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Laparoscopic right adrenalectomy
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摘要
The description of the laparoscopic right adrenalectomy covers all aspects of the surgical procedure used for the management of benign disorders (Conn's syndrome, small hormone-secreting tumors, Cushing's syndrome, small virilizing adenoma).
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.
Consequently, this operating technique is well standardized for the management of this condition.
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.
Consequently, this operating technique is well standardized for the management of this condition.
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媒體類型
 刊物
2001-07
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普通的
最愛
 音訊
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數位出版
WeBSurg.com, Jul 2001;1(07).
URL: http://www.websurg.com/doi-ot02en211.htm
URL: http://www.websurg.com/doi-ot02en211.htm
Laparoscopic right adrenalectomy
1. Introduction
The first adrenalectomy via a transperitoneal approach was performed in 1889 and the first laparoscopy was performed in 1912. It was not until 1992, however, that Gagner et al. performed the first laparoscopic adrenalectomy.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 hospital stay;
- reduced wound morbidity.
2. Anatomy
• Location
The right adrenal gland, which is larger than the left one, is an endocrine organ with a variable shape. It is located at the medial aspect of the upper pole of the right kidney, behind the vena cava in a very deep and high position (retroperitoneal position). Although located in the right renal fossa, it is not attached to the kidney.• Arterial vasculature
• Right superior adrenal pedicle
The right superior pedicle originates in most cases from the right inferior phrenic artery. It divides into short descending branches that enter the upper pole of the right adrenal gland.• Right middle adrenal pedicle
The right middle pedicle originates directly from the aorta. It divides into short branches that enter the central part of the adrenal gland.• Right inferior adrenal pedicle
The right inferior pedicle is located in an anterior inferior position relative to the gland. It usually originates from the right renal artery and divides into short branches that enter the inferior pole of the adrenal gland.• Venous drainage
• Main adrenal vein
The main adrenal vein originates from the right adrenal gland. It drains into the posterior lateral aspect of the inferior vena cava after a short horizontal course.• Accessory adrenal vein
In 4% to 10% of the cases, an accessory adrenal vein that originates from the gland is present. It drains into the right hepatic vein. Significant hemorrhage can occur if this vein is not controlled appropriately.The accessory right adrenal vein can also drain into the inferior phrenic vein.
• Variation in the main adrenal vein
In rare cases, the main adrenal vein can divide into 2 branches.3. Indications
Indications- 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).
Relative indication
Bilateral tumors are a relative indication considering the overall operative time necessary to perform such a procedure.
Contraindications:
Patient-related:
- 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.
4. Preop period
The workup and localization of benign adrenal tumors depends on the suspected underlying pathology. Standard workup consists of a detailed clinical history and physical examination complemented by appropriate laboratory and radiologic evaluation (CT, MRI, scintigraphy).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.
5. Operating room set-up
• Patient
- general anesthesia;- orotracheal intubation;
- full left lateral decubitus position;
- both legs slightly flexed to avoid crural neuropathy;
- cushion placed under left flank;
- table flexed to widen the space between the anterior iliac spine and inferior costal margin.
• Team
1. The surgeon stands on the abdominal side of the patient.2 + 3. Two assistants stand on the other side of the patient.
Two video monitors are used.
• Equipment
1. Operating table2. Anesthetic equipment
3. Laparoscopic unit
4. Monitors
5. Electrocautery
6. Instrument table
For optimal safety conditions, the operating room should be ergonomic, allowing ample space for the laparoscopic and anesthetic equipment.
6. Trocar placement
• Pneumoperitoneum
A pneumoperitoneum at 12 to 15 mm Hg is established in a standard fashion according to the operating surgeon's preference.Usually, only 4 trocars (10 mm) are necessary to perform a laparoscopic right adrenalectomy via the transperitoneal approach. The position of the trocars may vary with the patient's body habitus.
• Optical devices
The first 10 mm optical trocar is inserted in the anterior axillary line, under the costal margin. The 0° laparoscope is introduced through this trocar. In thin patients, it is preferable to introduce this first trocar under direct vision using the open technique.• Operating devices
A second 10 mm trocar is introduced 5 cm from the optical trocar, 2 cm anterior to the anterior axillary line.• Retractors
Two other 10 mm trocars are introduced under direct vision. Both are placed under the costal margin, 7 cm on either side of the optical trocar. Initially, a grasper is introduced through each trocar and used to expose the operating field to be dissected. The liver retractor will be introduced through the trocar on the left.
7. Instrumentation
• Optical devices
A 0° laparoscope is commonly used.A 30° laparoscope may be necessary, especially:
- in obese patients,
- in case of large tumors.
• Retractors
A second 10 mm trocar is placed inferior to the left costal margin, 10 cm from the xiphoid process. It is used to introduce a 5 or 10 mm grasper.8. Major principles
Our operative strategy is based on complete dissection of the right adrenal gland without specifically identifying the gland itself.The vena cava constitutes the main anatomical landmark in this strategy.
It is dissected first because it is easily identified and leads directly to the right adrenal gland.
The gland itself does not have to be dissected; only the vena cava and the right renal vein are dissected respectively, to the left and caudally, to determine the limits of the operating field.
9. Exploration
The right adrenal gland is located along the upper pole of the internal aspect of the kidney and sometimes covering it, especially in thin patients. The gland is surrounded by fatty tissue. It is firm yet extremely friable and therefore particularly difficult to manipulate during surgical procedures.Complete exploration of the abdominal cavity is possible with video-assisted surgery.
It enables identification of perisplenic or colonic adhesions, which could complicate the dissection.
10. Exposure
• Liver retraction
The right adrenal gland is situated behind the liver.Good exposure requires retraction of the liver from the operative field, allowing easier access to the vessels.
• Incision of the subhepatic peritoneum
The procedure begins with the incision of the subhepatic peritoneum using either a coagulating hook or scissors. This frees the triangular ligament from the liver, resulting in the complete mobilization of the liver.
The gallbladder, which is situated outside of the operating field, is left untouched.
• Mobilization of the liver
An atraumatic liver retractor is introduced through the extreme left trocar to delicately retract the liver cephalad preventing any injury. The liver must be maintained in a tension-free position during the entire procedure.The right adrenal gland can be identified in thin patients; it is more difficult to visualize in obese patients.
11. Dissection
• Identification of the vena cava
Mobilization of the liver allows identification of the vena cava (1). The vena cava is dissected caudally and then cephalad, exposing the renal vein (2), which constitutes the inferior landmark of the dissection, and then the main adrenal vein (3).• Identification of the renal vein
The dissection begins on the left aspect of the gland in order to expose the vena cava.The vena cava is then dissected caudally until the renal vein, which constitutes the inferior landmark of the operating field, is identified.
• Identification of the main adrenal vein
The dissection continues cephalad on the right aspect of the vena cava since it is the anatomical landmark used to identify the main adrenal vein.The main adrenal vein always seems to be situated lower than it actually is.
• Pitfalls and complications
In the common pitfalls related to the laparoscopic approach (bowel and vascular injuries, gas embolism, operative difficulties linked to adhesions, obesity, etc.), specific side-related problems can be observed.These are for a right adrenalectomy:
- liver injury;
- tear of an accessory adrenal vein joining an intrahepatic vein;
- injury of the vena cava;
- division of a superior polar renal artery;
- rupture of the capsula of the gland.
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.
12. Ligation of the veins
• Adrenal veins
The main adrenal vein (1) and the accessory adrenal vein (2) (if present) are then successively controlled and divided.• Main adrenal vein
The main adrenal vein has a very anterior position because the patient is in full left lateral position. The vein is therefore easily dissected for 1 cm and clipped under optimal safety conditions with 2 clips.
The vein is then divided and the gland retracted caudally.
• Accessory adrenal vein
The dissection continues on the inferior aspect of the liver to look for the accessory adrenal vein. If present (in 4% to 10% of the cases), it joins a right suprahepatic vein after a very short course.The accessory adrenal vein is dissected, clipped and divided.
13. Ligation of the arteries
• Middle adrenal artery
Dissection of the arteries is now performed.The gland can be retracted caudally and to the right using a peanut swab to facilitate the access to the medial arterial pedicle.
The middle adrenal artery, which originates from the aorta, is located either posterior or inferior to the main adrenal vein. It is identified and dissected from the aorta in the fatty tissue, and then clipped and divided.
• Superior adrenal artery
The gland is then retracted caudally using a peanut swab.The superior adrenal artery, which originates from an inferior phrenic artery, is identified at the upper pole of the gland below the liver. It is dissected, clipped, and divided.
At this point, the upper pole of the gland is completely freed from the liver. The gland is retracted to an inferior lateral position to allow the diaphragm to be liberated from all its attachments.
• Inferior adrenal artery
The inferior adrenal artery, which usually originates from the renal artery, is located on the posterior inferior aspect of the gland. The gland is retracted cephalad and to the right using a peanut swab and then completely freed on its right aspect. Its posterior attachments are all dissected free to allow the exposure, clipping and division of the inferior adrenal artery.The inferior pole and internal aspect of the gland are then completely freed from both the vena cava and the renal vessels.
• Orientation after traction
1. Upper pole renal artery2. Inferior adrenal artery
The surgeon must be aware that the traction exerted on the gland can modify the orientation of an upper pole renal artery, which could be mistaken for the inferior adrenal artery.
14. End of procedure
• End of the dissection
At this point in the procedure, the vascular network of the gland is almost completely divided. The goal is to free the gland completely and proceed to its extraction.The few attachments located between the inferior external aspect of the gland and the upper pole of the kidney are carefully dissected using either a monopolar coagulating hook or a bipolar grasper.
• Extraction
The gland, now completely free, is grasped with an atraumatic grasper and introduced into an extraction bag.The extraction itself is performed through a trocar opening that can be slightly enlarged depending on the individual case.
A drain can be placed for 24 hours.
• Control and closure
Hemostasis is immediately checked.Each 10 mm trocar incision is closed using absorbable sutures.
A closed suction drain may be left in the surgical bed.
15. Postop period
- the patient may ambulate on the same day.- liquid intake resumes the night of the procedure.
- a normal diet resumes on the first postoperative day.
- the patient may leave the hospital on POD2 or POD3.
16. Reference
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Castillo OA, Vitagliano G, Secin FP, Kerkebe M, Arellano L. Laparoscopic adrenalectomy for adrenal masses: does size matter? Urology 2008;71:1138-41.
Dimas S, Roukounakis N, Kafetzis I, Bethanis S, Anthi S, Michas S, Kyriakou V, Kostas H. Feasibility of laparoscopic adrenalectomy for large pheochromocytomas. JSLS 2007;11:30-3.
Duh QY, Siperstein AE, Clark OH, Schecter WP, Horn JK, Harrison MR, Hunt TK, Way LW. Laparoscopic adrenalectomy. Comparison of the lateral and posterior approaches. Arch Surg 1996;131:870-5; discussion 875-6.
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Kebebew E, Siperstein AE, Clark OH, Duh QY. Results of laparoscopic adrenalectomy for suspected and unsuspected malignant adrenal neoplasms. Arch Surg 2002;137:948-51; discussion 952-3.
Kercher KW, Novitsky YW, Park A, Matthews BD, Litwin DE, Heniford BT. Laparoscopic curative resection of pheochromocytomas. Ann Surg 2005;241:919-26; discussion 926-8. Surg Oncol 2003;12:105-23.
Lal G, Duh QY. Laparoscopic adrenalectomy--indications and technique.
Linos DA, Stylopoulos N, Boukis M, Souvatzoglou A, Raptis S, Papadimitriou J. Anterior, posterior, or laparoscopic approach for the management of adrenal diseases? Am J Surg 1997;173:120-5.
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Parnaby CN, Chong PS, Chisholm L, Farrow J, Connell JM, O'Dwyer PJ. The role of laparoscopic adrenalectomy for adrenal tumours of 6 cm or greater. Surg Endosc 2008;22:617-21.
Toniato A, Boschin IM, Opocher G, Guolo A, Pelizzo M, Mantero F. Is the laparoscopic adrenalectomy for pheochromocytoma the best treatment? Surgery 2007;141:723-7.