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Laparoscopic right adrenalectomy

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Laparoscopic   right   adrenalectomy

作者群
D Mutter, J Marescaux
關鍵字
laparoscopic adrenalectomy,anterior approach
媒體類型
期間
17'05''
刊物
2005-05
普通的
最愛
Favorites Media
音訊
en
副標題
en
數位出版
WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-vd01en1801.htm

Laparoscopic   right   adrenalectomy

3. Opening of peritoneum 01'00''
and as on the left side, it’s very important to mobilize the spleen on the right side. The key is to mobilize the liver. The adrenal is located below the liver. I’m here below the liver. I can identify the vena cava here. I will not immediately go on the vena cava. All these adhesions are coagulated. The objective is really to mobilize all the adhesions around the gland and to mobilize the liver. The hook also allows a very easy coagulation and freeing of the liver, avoiding here any bleeding. The liver retractor, very smooth, will allow to very gently lift the liver. The objective of the assistant will be to turn just with this light movement, with some tension exerted not too much to avoid disrupting the adhesion that has to be coagulated before removal. The major danger at this low dissection below the liver is to have the adrenal gland joining directly the liver, which is present in about 15% of cases with a risk of bleeding coming from the liver that could be very difficult to control. When we are at the edge between the liver and the vena cava, we open the peritoneum along the vena cava, which will represent our left landmark of dissection. This dissection is just performed over the vena cava, and its inferior limit will be the beginning of the left renal vein. So I go ahead with the opening of the peritoneum. You can see that thanks to the lateral position of the patient, we have no problems with the duodenum. Now I will free the lateral border of the vena cava with the objective to identify the main adrenal vein. In a standard case, it’s not difficult to identify all these little fibrous adhesions. I go ahead with the lateral dissection of the vena cava. The cautery is set very low (on 20-25) in order to coagulate every small vein. We are used to working with a 0 degree scope. Here you can see that the distance between the gland and the liver may be very small, it’s almost an adhesion between the adrenal gland and the liver. Nevertheless, every millimetre can be dissected gently to avoid bleeding. The objective is to lower the gland to put it at distance from the liver and from the vena cava. This mobilization will allow to lengthen the vein even if it appears initially as short, we have the place to apply safely and very early 2 clips. So here probably again I have the adenoma. Here you can see very little superficial veins. Here you can see a direct vein most probably joining the liver and going in the vena cava. It is a very small one, less than 1mm. But if you have a tear in this vein such as a vena cava bleeding, and here it’s the hepatic accessory vein, very small one, but if you don’t identify it, if you have some dirty operative space, maybe at the origin of a lot of troubles in terms of color and anatomical recognition. So here again I free all these little attachments because when I mobilize the gland there is always a risk of bleeding. And you see the importance of the positioning of the retractor here. Now I have mobilized the gland. We have here some very small adhesions. I control the lateral side of the vena cava. Here is the medial side of the gland. Here thanks to the lateral position of the patient, I have no part of the gland that appears behind the vena cava, but the patient is in lateral position so the whole gland is lateral to the vena cava.
5. Adrenal artery 07'50''
It can be controlled with either bipolar cautery or Ligasure. I will make sure to avoid removing the previous clip with my clip applier. I will check the upper part here by mobilization of the gland close to the liver. The gland is almost impacted in the liver. And there is the risk of having a second vein with hepatic vein drainage. The objective is to identify the diaphragm. You see how important it is to have extensive mobilization of the liver. Here you can see that there is a dense adhesion between the gland and the liver. Sometimes the adrenal resection goes into the liver and I agree that it is a place where you can have an accessory vein directly joining the liver. Here we can note that anatomically the internal part of the peritoneum has a reflection line between the adrenal gland and the liver, and when we have such a dense adhesion, we should find a plane (much easier to find in laparoscopy than in open surgery, when you are in a bad condition to free the posterior aspect of the liver). Here I open this reflection line very gently. I now identify the upper edge of the gland. I have just the internal part to dissect and again there is a vein here. Here you see that it could have been dangerous to go immediately there without complete freeing of the upper part of the gland and now I have lengthened this vein and it will be much easier for me to apply clips because this upper part is also free. Now we have a nice lateral vein. This one runs a bit more posterior than usual. We have got an anterior artery and usually the artery is posterior to the vein, and here we have an artery that is anterior to the vein. I will now apply clips. We have a safe dissection. You see that the gland goes away. I’ve got the medial artery. I move to the upper pole of the gland and I will look for the superior artery. I think the main superior artery is here. This is the vascular pedicle and here is another one. As it is so small, I will control it using cautery. And now I go here along the muscle, behind the gland and now I’ve completed the upper dissection of the gland. I will do the same laterally on the side of the vena cava. One artery is missing. It is the inferior one usually coming from the renal artery. So I have to identify it very lower and now I have to mobilize the gland completely on its interior edge. Here there’s probably a little pedicle coming from the aorta here. I would like to free the internal angle of the gland. I proceed slowly. It’s important to have a good cautery here because with the approach we have until the end of the procedure, we have some bleeding coming from this place, behind the vena cava. It is a place where we don’t like to go again and to perform cautery which is done. There is a risk of blind cautery. Here you see that most of the internal and upper dissection is completed. The gland is mobilized. Here again a little branch can be seen. The inferior pole remains here. I will check if I see the origin of the renal vein. Here the vena cava goes down in this direction. This might be the origin of the renal vein. From this angle which may be difficult to dissect in case of pheochromocytoma or big tumor due to the nodes, I will find the vascular pedicle. Now we will have to open here. Any system is good.