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Laparoscopic three-port left adrenalectomy for a 5cm Cushing's adenoma

We report the case of a female patient presenting with a Cushing's adenoma. It is located on the left side of the patient. This woman has a previous medical history of type II diabetes and obesity. She presents clinically with a typical Cushing’s syndrome. A laparoscopic three-port left adrenalectomy is demonstrated.

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Laparoscopic three-port left adrenalectomy for a 5cm Cushing's adenoma

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D Mutter, J Marescaux

摘要

We report the case of a female patient presenting with a Cushing's adenoma. It is located on the left side of the patient. This woman has a previous medical history of type II diabetes and obesity. She presents clinically with a typical Cushing’s syndrome. A laparoscopic three-port left adrenalectomy is demonstrated.

關鍵字

Laparoscopic adrenalectomy, three-port adrenalectomy, left adrenalectomy

媒體類型

手術影片

期間

09'41''

刊物

2011-03

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Mar 2011;11(03).
URL: http://www.websurg.com/doi-vd01en3214.htm

Laparoscopic three-port left adrenalectomy for a 5cm Cushing's adenoma

1. Clinical case 00'11''

We report the case of a female patient presenting a Cushing’s adenoma. It is located on the left side of the patient. This woman has a previous medical history of type II diabetes and obesity. She presents clinically with a typical Cushing’s syndrome. Biologically, this patient presents a free urinary cortisol and an elevated plasmatic cortisol level with a low ACTH level. CT-scan shows a 5cm tumor located on the left adrenal gland. There is no sign of carcinoma. We decided to perform a laparoscopic left adrenalectomy. The patient is placed in a full lateral position. We usually start the procedure by inserting three ports. A fourth one can be inserted, if necessary, during the dissection. This will not be necessary in this patient.

2. Trocar placement 01'09''

The first 12mm port is inserted in an open way, and two further 10mm ports are placed in order to insert cautery, the grasper, and the little peanuts. We always start by freeing some adhesions over the left colon. The manipulator inserted on the side of the operator’s left hand is used. This allows to have a nice and complete access to the inferior edge of the spleen.

3. Dissection of peritoneal reflection behind the spleen 01'43''

Dissection is started by the freeing of the peritoneal reflection behind the spleen. This will allow to mobilize the spleen towards the right side of the abdomen. The weight of the spleen is used as a traction device to expose the operative field. The dissection plane is along Gerota’s fascia. This will allow to mobilize together the spleen and the pancreas. This is a complete avascular field that will allow to progressively identify the renal artery, the renal vein, and the adrenal vein.

4. Renal vein identification 02'27''

The main landmark we are looking for after dissecting the tail of the pancreas will be the renal vein. It is very important to avoid any injury of the renal vein and to avoid any confusion between the renal vein and the adrenal vein.

5. Main adrenal vein dissection and control 02'52''

The main adrenal vein is dissected over a length of 1 to 2cm with a very nice and clear identification of the renal vein. This will allow for a safe dissection and a safe control of the main adrenal vein. The right angulated grasper is placed behind the vein in order to make sure that it is completely free. The first clip will be applied just at the level of the renal vein. Two further clips will be placed, one below and one over the division area. After control of the main adrenal vein, the next vascular element will be the medial adrenal artery. This medial artery originates from the aorta. It is the first landmark allowing to completely free the internal side of the adrenal gland. The dissection is conducted posteriorly until the identification of the laterovertebral muscles. This dissection will allow to completely free and take away the gland and all its surrounding fat.

6. Medial adrenal artery identification and control 04'26''

The medial adrenal artery is very well identified and controlled with the right angle just below the origin of the accessory adrenal vein. This artery is controlled by applying two clips. A very small bleeding is controlled with bipolar cautery in order to keep a bloodless operative field. It is necessary to clearly identify the anatomy during the whole dissection. The gland is freed upwards.

7. Accessory adrenal vein control 05'04''

The next vascular element that is crossed during this dissection is the accessory adrenal vein. This was previously identified and it crosses clearly the operative field. This will be controlled again by applying 2 clips and by dividing in order to have the possibility to continue the dissection of the gland upwards.

8. Superior adrenal artery control 05'33''

The last vascular element located on the right side of the gland is the superior adrenal artery. This artery originates from the inferior diaphragmatic artery. It is dissected, controlled with clips, and divided. Herein, the gland is completely free on its internal right border. All the gland and its surrounding fat is removed on this side. The dissection will be conducted at the upper pole of the kidney, again in order to remove the whole gland and its surrounding fat. The dissection plane must identify the upper pole of the kidney. Dissection helps to free the lateral and inferior border of the gland. Bipolar cautery allows to control some oozing of several vessels. Dissection of the inferior part of the gland joins the dissection that was previously performed close to the hilum of the gland. Here, we are looking for the inferior adrenal artery. This artery must be clearly identified in order to avoid any injury of an accessory renal artery, which may be located very close to this area.

9. Dissection of kidney\'s upper pole 07'09''

The upper pole of the kidney is cautiously freed from any adhesions and every fat surrounding the gland. Monopolar cautery is a very interesting tool for this type of dissection. The last adhesions at the inferior horn of the gland are free. The gland is clearly identified and the inferior artery can be isolated thanks to very close cautery of all its surrounding tissue.

10. Inferior adrenal artery control 07'49''

The inferior adrenal artery represents the last vascular landmark surrounding the gland. It is controlled with 2 clips and can be divided after this control. All the vascular elements have been identified and controlled: the main adrenal vein, the accessory adrenal vein, and the three main vascular pedicles representing the medial artery, the superior artery, and the inferior artery.

11. Freeing of last attachments 07'21''

The last attachments of the gland are freed using hook, scissors or any other sealing or division device.

12. Gland removal 08'31''

The gland is completely free into the abdomen. The whole adrenal area is removed. The gland will be inserted in a bag in order to allow for a very safe removal without any contamination of the parietal wall. The dissection area will be carefully checked in order to be sure that there is no further bleeding coming from any dissection space. Here, a little blood oozing allows to discover two little bleeders that will be controlled with bipolar cautery. Thanks to the patient’s position, we see that we have a nice exposure of the operative field allowing the resection of this 5 by 8cm adrenal tumor.