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Laparoscopic right adrenalectomy

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Laparoscopic   right   adrenalectomy

作者群
D Mutter
關鍵字
operation,endocrinology,right adrenal glands,resection
媒體類型
期間
20'00''
刊物
2005-09
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, Sept 2005;5(09).
URL: http://www.websurg.com/doi-vd01en1179e.htm

Laparoscopic   right   adrenalectomy

1. Case presentation 00'40''
I will show you briefly the installation of the patient. Subcostal margin, the anterior axillary line, I place 4 ports to perform this operation. The first port is placed by open laparoscopy, it will be for the optic, a 12mm optic, which is placed under the costal margin on the anterior axillary line. I then place two operative ports, which are 5cm on the right and the left sides of the operative one, they are 10mm ones. I have a 5mm port placed very high close to the epigastric zone in order to receive the hepatic retractor. When we operate on the left side, we place a 10mm port here because we use other instruments, but on the right side, we only use the hepatic retractor, and so a 5mm port can be used for the whole operation. I see the attachment of the triangular ligament of the liver, I can see the liver completely, here I have the hepatic retractor and the liver is here. Initially, I cannot mobilise the liver so the first step of the operation will be the mobilisation of the liver. To perform this, I will have to cut the triangular ligament of the liver and mobilise the liver as high as possible. This will be a long part of the operation because we really have to mobilise completely the liver because the adrenal gland is behind the liver. Here you see that I place the retractor in order to retract the liver, we avoid excessive traction that could lead to injury of the liver, which is the main problem and that is why we use a very atraumatic retractor. If the cautery of the coagulation of the attachments of the liver are not done very well, there is a risk of bleeding, if it is not a big problem for safety it is a big problem for the identification of the colours of the gland and of the whole operative field. The principle of the operation will be to identify all the landmarks. I will follow what we call a vascular strategy; after mobilisation of the liver, I will progressively identify the vascular operative landmarks. These landmarks will be the vane cava first, which will allow to identify the position of the adrenal gland and then the arteries of the adrenal. The patient is on a 10 degree turn on the back, his head is on this side, here is the back, here is the abdomen. I am on the abdominal side, I work with the 2 ports that you see here, optic and liver retractor. The patient is in a lateral position. He is slightly bent and has tissue behind the left costal margin. Here you see that I take care to avoid any traction on the adhesions because we know that in such patients the liver can very easily have a small parenchymal injury and this would lead to a permanent bleeding in the operative field. I really want to avoid blood in the operative field because colours allow identification. I do again what I have done, going from the right to the left side, the objective of the resection of an adrenal gland is always to remove what we call the adrenal area; I will not only remove a gland with a nodule on it but I will remove the fat with all the peri-gland tissue with the fat that is around it in order to avoid injury of the gland and avoid adrenal tissues being kept in place. Here you see that we have to go more medially in order to identify the vena cava. Now I want to identify my medial dissection landmark, the upper landmark is mostly completely identified below the liver. We have identified this vein in around 5% of our cases operated on by laparoscopy. This identification is very important because if you have an injury of an accessory adrenal vein that joins the supra-hepatic vein, operatively it represents a supra-hepatic injury and this can lead to major bleeding that is very difficult to control because the vein is intra-hepatic; for the surgeon, it will be very difficult to control. Now I will leave the hepatic border a little bit and I will try to find the internal plane. I will open the peritoneum cover along the vena cava, here again very gently. The objective of this dissection now is to define my internal dissection plane. We know that we have to dissect progressively up to the renal vein, which will represent the inferior part of our dissection plane. It will be interesting to see if the position of the patient avoids, and we see this every time, any problem with the duodenum and the right colon. That is I think the major difference between an approach with the patient lying supine and our lateral position; we never have to dissect the duodenum or the right colon. This is a major advantage to avoid injury to these elements. Here you see that I have a very good identification of the vena cava. The danger of monopolar cautery is very low if some conditions are respected. The first condition is to have modern electrocautery avoiding any sparks between the hook and the tissue, here I have no sparks and very gentle cautery and if I take too much tissue, it does not work. It only works if I have a filament of tissue. The gland is lateral to the vena cava due to the position of the patient. My objective is to free the right side of the vena cava here and automatically, I will join the adrenal vein because the adrenal vein is between the renal vein, which will be a little bit lower and the upper pole of the liver. When we go slowly upwards, we see that the adrenal vein will be here. The dissection of the adrenal vein is always a problem because it is surrounded by very small vessels and frequently we have small bleeding around it. We know that the adrenal vein is theoretically very short but you can lengthen this vein in the same way as you would lengthen a hepatic pedicle when performing a hepatectomy. By dissecting slightly slowly the fibrous tissue all around it, you can obtain a longer aspect of the vein in order to very safely apply your clips and the objective will be to have 2 clips on the side of the vena cava because we consider that one control of the vena cava for one operation is enough for my adrenal. Again, I will mobilise the liver, you see that I did not identify correctly the angle between the vena cava and I would say the diaphragm. Progressively I identify my vena cava over the adrenal vein, 1cm over I think; once I have identified it very high and very low, I will progressively go closer from the adrenal vein. But I always remember that I will have to apply clips somewhere and so I want to have a large operative space to have safe clip application. Now I will go on the fibrous elements of the vena cava, very frequently in this tissue, there are some very little veins, I want to free all the elements on the vena cava and we can lengthen this vein, even in this fatty patient, of about 1cm. I will take 10mm clips in order to have a safe control of the vein, the next one is put a little bit blindly but I will control, with pheochromocytoma it’s much bigger. We are respecting the rule that must always be respected in laparoscopy, we never cut a vessel in one go, we cut half of it and if it bleeds, it is very easy to apply another clip, and then you can finish your dissection. You have finished the major venous control; on the left side, you always have an accessory vein, but on the right side, it is not so frequent. You see this fatty tissue, it can bleed. I will try to identify this artery somewhere there in the fat. There is a risk of blood increase in the gland, even in open laparoscopy, it was not easy due to the fat. I think that here I have the upper pedicle. We can identify all the muscular fibre on the diaphragm. Here I have something very interesting, I see the border of the gland here with the upper pole of the gland and here I am on the diaphragm. This means that I have completely mobilised the posterior pole of the gland from behind the vena cava, taking away all the fat. The inferior artery will be found during the dissection of the renal vein, and just over the renal vein I will have the inferior artery coming from the renal artery. I will use ultrasonic dissection for the fat over the kidney, but before this I want to identify all the vessels and here identify completely the diaphragm, I take all the fat and all the gland; when this is done, then I consider that the difficult part of my dissection is complete and I will have the possibility to use the ultrasonic dissector but the quality of the image will not be so nice with this dissection and the fat. You can have some small bleeding if you cut half of a vessel, so I prefer to control all the vascular elements first with a perfect image, and then when this is done, just remove the fatty aspects. Here I can show you the renal vein, vena cava, origin of the renal vein, it is really the lower part of my dissection so you can see that you have the inferior limit of your dissection is here with the identification here of the origin of the renal vein. If you have an artery that doesn’t seem totally in the direction that it should be, going directly to the vein, you should dissect it on the longer way in order to be sure that it is an adrenal one. Here you see that the internal part is completely finished, we are on the diaphragm, here we are on the inferior border of the gland, and now we have to open up this fat here between the upper pole of the kidney that we can identify here somewhere. We will open the fat first and then we are going to free the gland, the kidney is here. We are sure that we are on the inferior pole of the gland here so our dissection will start here internally and will go to the right side. The second problem of adrenalectomy is how to grasp the tissue and how to present the tissue. If we could have a nice atraumatic instrument to grasp the tissue without injuring it, we would enjoy it. My first step is to open the peritoneum, sometimes you have a vein, I coagulated previously here. Here again, I don’t want to see the gland, I want to see the kidney. Here I see the kidney, now that I have identified the kidney and that I am in the right plane, I will take away all the gland with the whole fat. We have never seen the gland, just a little bit the colour at the beginning if you remember, as always otherwise we have never seen the gland and I think to perform a correct adrenalectomy, we must not see the gland, that is why I don’t believe the surgeon who describes the ultrasonography to recognise the gland.