WebSurg中文版尚未完成，翻譯工作進行中！

Laparoscopic right adrenalectomy for pheochromocytoma using augmented reality

Laparoscopic adrenalectomy is a well-established procedure. This is the case of a patient who has undergone a surgical laparoscopic procedure for a typical secreting right pheochromocytoma. The CT-scan shows a 6cm tumor. Preoperatively, virtual reality is used. The objective is to accurately locate the tumor, its relationships with the surrounding anatomical structures and the position of the adjacent organs, and to prepare the surgical intervention in ideal conditions.

建立帳號

瀏覽全世界

繁體中文 ▼

Google translate

總結
章節
您的意見
詢問專家群

欲觀看此影片請先登入！

於WEBSURG-HD購買此高畫質影片

Laparoscopic right adrenalectomy for pheochromocytoma using augmented reality

作者群

D Mutter, L Soler, J Marescaux

摘要

Laparoscopic adrenalectomy is a well-established procedure. This is the case of a patient who has undergone a surgical laparoscopic procedure for a typical secreting right pheochromocytoma. The CT-scan shows a 6cm tumor. Preoperatively, virtual reality is used. The objective is to accurately locate the tumor, its relationships with the surrounding anatomical structures and the position of the adjacent organs, and to prepare the surgical intervention in ideal conditions.

關鍵字

Laparoscopic right adrenalectomy, secreting pheochromocytoma, augmented reality, tumor

媒體類型

手術影片

期間

14'12''

刊物

2010-10

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Oct 2010;10(10).
URL: http://www.websurg.com/doi-vd01en2952.htm

Laparoscopic right adrenalectomy for pheochromocytoma using augmented reality

1. Clinical case presentation 00'10''

We report the case of a patient who has undergone a surgical procedure for a typical secreting pheochromocytoma. According to the imaging study, the tumor is located at the level of the right adrenal gland. The CT-scan shows a 6cm tumor. Preoperatively, virtual reality is used. This consists in the reconstruction of the patient’s anatomical structures. The objective is to accurately locate the tumor, its relationships with the surrounding anatomical structures and the position of the adjacent organs, and to prepare the surgical intervention in ideal conditions. Successively, the normal adrenal gland, the tumor, its vascular relationships as well as its relationships to the adjacent organs will be demonstrated. The surgical procedure is planned.

2. Patient and trocar position 01'10''

Usually, the patient lies in a left lateral decubitus position. Four ports are inserted, amongst which one trocar for the camera, 2 operating trocars and an epigastric trocar for liver retraction. The liver is retracted by means of an atraumatic retractor.

3. Peritoneal opening 01'28''

The dissection is performed using an AutoSonix® ultrasonic dissector in order to open the peritoneal layer, preventing blood oozing from occurring. Indeed, the preservation of a correct vision necessitates that bleeding be avoided at all cost as this would alter the image quality.

4. Dissection in contact to the vena cava 01'51''

The dissection is started by opening the peritoneum in contact to the vena cava, then progressively at the level of the peritoneal fold, below the liver. As the superior portion of the gland is situated posterior to the liver to the right, it is mandatory to retract the liver in order to gain access to the adrenal fossa. This mobilization is essential in order to perform a totally safe exposure of the adrenal fossa. Some permanent slight tension at the level of the liver is exerted by the assistant now holding the liver retractor. An ultrasonic dissector is used by the operator but, even so, a bipolar forceps is used in order to gain a complementary coagulation of the small vascular structures that may bleed.

5. Identification of right renal vein 02'46''

Once the liver has been mobilized, the dissection is pursued on the lateral border of the vena cava. The dissection of its right lateral border will allow to identify the origin of the renal vein at the lower portion of the dissection area, progressively moving from caudad to cephalad in order to identify the main adrenal vein. The main adrenal vein is not always visible, especially in adipose patients or in patients presenting with a hypervascularization, as it is the case here, when there is a pheochromocytoma.

6. Use of augmented reality for vascular supply identification 03'18''

Augmented reality will prove very effective in this case, as the image that has been reconstructed using virtual reality will be superimposed on the operating image. This will allow for the identification of the position of the adrenal vein before actually seeing it. Consequently, the dissection of the planes on each side of the adrenal vein will be made possible in a completely safe way. The main difficulty when using augmented reality lies in obtaining a perfect superimposition between the operating image and the computer-aided reconstruction. This superimposition is carried out manually by a computer scientist with good anatomical knowledge. The small accessory veins, in contact to the adrenal capsule, are often coagulated in a complementary way by means of the bipolar forceps.

7. Accessory adrenal vein 04'11''

An accessory adrenal vein can be seen at the lower portion of the image. It courses from the adrenal gland towards the right renal vein. This anatomical specificity can be found in 10% of the cases. It is important to identify it in order to avoid any venous wound that may be accompanied by a significant hemorrhage.

8. Identification of main adrenal vein 04'33''

The dissection is pursued on the right lateral border of the vena cava, caudad to cephalad. The whole of the vascular and fibrous tracts is coagulated using both monopolar and bipolar cautery. The objective is to completely mobilize the superior internal angle of the gland in order to isolate the whole main adrenal vein and to control it in contact to the vena cava in a completely safe fashion. The dissection is progressively pursued in a stepwise fashion in order to avoid the effraction of the vein, which could lead to an important hemorrhage, which would be uneasy to control. The opening of the peritoneum is pursued caudally at the level of the right renal vein in order to enlarge the dissection plane and to retract the gland away from the renal vein. Once again, augmented reality is added to the image and allows for a perfect identification of the accessory inferior adrenal vein, coursing from the adrenal gland towards the right renal vein. A small swab can also be used in order to absorb the few vascular effractions in contact to the vein. It will also be used for compression purposes should an important bleeding occur, hence allowing to control a small vascular injury by applying clips or by using monopolar or bipolar cautery. The augmented reality demonstrates that the main adrenal vein is perfectly identified by superimposing both images. Since the main adrenal vein has been dissected at the level of its lower pole, then at the level of its upper pole, its posterior portion should now be freed. This is a blind maneuver, so it will have to be performed slowly and cautiously in order to coagulate all small veins that may bleed at this level.

9. Vascular control and adrenal vein division 06'38''

As we are dealing with a secreting tumor, a first vascular control should be carried out before performing any complementary mobilization of the gland. A right-angled clamp is ideally used to control the vein. Not only does it allow to safely pass posteriorly, but also to laterally clamp the vena cava should a vascular effraction occur. Augmented reality confirms the good quality of the dissection. The adrenal vein will then be controlled by applying clips. Usually, two clips are positioned on the side of the vena cava and another one is placed on the gland’s side. The length of the vein’s dissection will not allow, in most cases, to apply any additional clips. The vein is progressively divided in order to place an additional clip should the hemostasis be incomplete. Since this vein has been controlled entirely, the superior internal angle of the gland will be freed. In 10 to 15% of cases, a vein directly draining into a hepatic vein may be found. It is often difficult to find this vein. In the present case, the mere positioning of the hook posterior to this vascular pedicle causes a small hemorrhage. Due to the presence of a typical vein at this level, a clip is used immediately; it helps to control the bleeding. This vascular pedicle can then be divided safely and the dissection at the superior border of the gland at the lower pole of the liver may be pursued using monopolar cautery. The retraction of the gland remains difficult because of its size. The pheochromocytoma is relatively rigid and any effraction should be avoided to preclude any cell contamination related to a potentially malignant pheochromocytoma.

10. Inferior dissection 08'48''

The superior part of the dissection is now complete. The inferior and external part of the dissection should be carried out. The limit between the adrenal tumor and the kidney’s upper pole, marked by a groove, is identified. Ultrasonic dissection will be used to open the peritoneal reflection. This will allow to progressively find the gland’s inferior pole by identifying the kidney’s upper pole. Indeed, as usual, the entire peri-adrenal region and fat are completely resected in order to avoid any capsular effraction at the level of the gland. The entire fat surrounding the adrenal gland should be removed. The dissection is extended through the peritoneum until the area that has been previously dissected underneath the liver. Once again, large draining veins can be found. These are perfectly controlled using bipolar coagulation. The gland’s inferior pole is often irrigated by a more important lymphatic and venous drainage. As the renal vein has been perfectly identified, it is possible to perform an “en bloc” division of its pedicle elements using the Ligasure® device. This allows to prevent any untimely bleeding in this dissection area. One must make sure that there are no arterial elements that may correspond to a superior vascular pedicle of the kidney. The kidney’s upper pole is well identified here. The adipose cellular structures between the adrenal gland and the kidney are progressively coagulated using either the ultrasonic dissector or the Ligasure® device.

11. Posterior external dissection 10'48''

The posterior external dissection of the gland is now complete. The gland remains attached by its internal and posterior vascular elements that will be controlled last. The gland’s inferior pole is well identified. The renal vein is identified with certainty to prevent any risk. The inferior adrenal pedicle is placed under tension using a slight pressure on the gland achieved by a swab. The vascular elements are controlled progressively and safely by the Ligasure® device. It also allows to avoid a dissection that is always difficult in the presence of a pheochromocytoma. The gland is never manipulated by a forceps. It is only retracted along all its axes. The position of the Ligasure® device is changed at the level of the operator’s left hand. This allows to dissect the internal posterior and inferior part of the gland once it has been divided. The gland’s posterior aspect is totally freed.

12. Completion of gland mobilization 12'00''

Since it is uneasy to immediately mobilize the gland, its internal border, usually freed first, will be freed last in the present case. The gland is mobilized. A very slight tension is exerted and the attachments of the middle adrenal arteries are controlled at this moment, also using the Ligasure® device. This also allows to progressively place tension on the nervous, cellular, and adipose elements at the posterior and inferior portions of the vena cava. The Ligasure® device demonstrates a true efficacy here and simplifies significantly the gland’s mobilization. Small blood oozing is still possible. If any, they will be controlled using bipolar cautery. The superior pedicle is controlled last, still using the Ligasure® device. The pheochromocytoma, along with its hypervascularization, requires an adaptation of the means of dissection. Whereas the primary vascular approach of the adrenal vein must be the rule in order to avoid hypertensive bouts, the vascular control of the other elements should be adapted to the gland’s size. In the current case, and in the presence of a 6cm rigid and hypervascularized gland, it is necessary to adapt the technique. In the present case, the primary vascular freeing of venous elements has been achieved. The gland’s inferior pole has then allowed to progressively identify the inferior and internal vascular pedicles. These are also coagulated using bipolar cautery out of safety here.

13. Specimen extraction 13'49''

The gland with its intact capsule will be introduced into an extraction bag that is then removed through a slightly enlarged trocar introduction site. The pathological exam will confirm the presence of a pheochromocytoma of the adrenal gland scaled score PASS 4. There is no capsular effraction. The tumor measures 5 by 6cm.