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Posterior approach to laparoscopic left adrenalectomy including virtual reality simulation

Since M. Gagner published the first case of a transperitoneal laparoscopic adrenalectomy in 1992, the laparoscopic adrenalectomy has gradually become the standard operation for removing adrenal tumors. Compared to a traditional adrenalectomy, a laparoscopic adrenalectomy has a number of advantages, including less blood loss, a shorter hospital stay, a quicker recovery, and fewer complications. There are many ways to approach the adrenal gland laparoscopically, such as by a lateral transperitoneal approach, anterior transperitoneal approach, lateral retroperitoneal approach, and posterior retroperitoneal approach. This video shows a posterior left adrenalectomy using virtual reality simulation.

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Posterior   approach   to   laparoscopic   left   adrenalectomy   including   virtual   reality   simulation

作者群
M Walz, L Soler, J Marescaux
摘要
Since M. Gagner published the first case of a transperitoneal laparoscopic adrenalectomy in 1992, the laparoscopic adrenalectomy has gradually become the standard operation for removing adrenal tumors. Compared to a traditional adrenalectomy, a laparoscopic adrenalectomy has a number of advantages, including less blood loss, a shorter hospital stay, a quicker recovery, and fewer complications. There are many ways to approach the adrenal gland laparoscopically, such as by a lateral transperitoneal approach, anterior transperitoneal approach, lateral retroperitoneal approach, and posterior retroperitoneal approach. This video shows a posterior left adrenalectomy using virtual reality simulation.
關鍵字
Posterior approach, laparoscopic left adrenalectomy, virtual reality simulation
媒體類型
期間
31'12''
刊物
2011-09
普通的
最愛
Favorites Media
音訊
en


數位出版
WeBSurg.com, Sept 2011;11(09).
URL: http://www.websurg.com/doi-vd01en3413.htm

Posterior   approach   to   laparoscopic   left   adrenalectomy   including   virtual   reality   simulation

2. Introduction 01'00''
See here the CT-scan of this patient with clear left adrenal tumors. You may zoom in of course. There are indeed 2 nodular areas, this one here in this part of the adrenal gland, and this is the second part corresponding to the second area. In 3D, we can see it so Professor Walz, can you see it? Yes, I can see everything. What do you want to see precisely? Well, let’s show us the situation from the anterior face, you know just like this. So you can see here the anterior view and we can see the green tumors in the back here; we have to go to the back to get a better view of these tumors, and I remove bones. Thank you for turning the patient around, and as you all can see that if you are coming from the back, the tumor is exactly in the old direction. So the posterior approach to the adrenal gland is very direct and very simple access and I’m happy that this 3D reconstruction shows us exactly what we wanted to show you. See the patient has a relatively long 12th rib and the tumor is just somewhere behind that rib so the idea is to go beneath the 12th rib and to access the tumor of the adrenal gland from the back. And we have also prepared a little bit the view we will have at the beginning. We’ll put the camera at the middle, just somewhere there, just beneath the 12th rib and we look inside, and with a grasper coming from far lateral, we will mobilize the kidney in the beginning. And after we have mobilized the kidney, and pushed it a little bit down, we will have an excellent access to the adrenal gland from the back, independent how the ribs are. So what you can see here is the last position with the laparoscopic camera as planned yesterday together. See the position of this camera and you have the laparoscopic view and to the second window here. So you will introduce the camera here in the second position if I understood well. Yes, indeed. And then, a grasper in the initial position of the camera and another grasper behind with a retraction of the kidney and this retraction can also be visualized here. Here you can see the retraction of the kidney with a different tool positioning that will allow to have all instruments in the visual field to reach the tumors. May I introduce my direct teams, Dr. Sucik beside me taking the camera, and Peggy, the scrub nurse, with the patient’s head opposite us. I think we will have a nice operation.
4. Trocars position 05'38''
You must go a little bit more medially, and therefore we start at that point so this will be the open access, and I will do a 1.5cm incision so that my finger can go in; that’s my idea. We do the first incision here, 1.5cm, then I need the scissors; my finger goes to the bone as near as possible just to the bone. I open the retroperitoneum like this, I go in with my scissors a little bit, spread the scissors, open the scissors, come back and now I have a hole in the retroperitoneum. Next point is I bring in my finger: now my finger is in the retroperitoneum and I can feel the end of the 12th rib and part of the 11th rib so the next incision will be for the 5mm port lateral. I do the incision just there. And I will take the 5mm port, I take this one with a screw on it so that it will not remove and it is a reusable one as we love to use reusable ones. So I put this in and my finger is on the other side of the abdominal wall and there is nothing between, except skin, fascia, muscles so I put in this port under control of my inside finger like this, and now you can see I can move this port with my finger so there is a connection between this and this. Now I have to turn a little bit and I will show the next port and the 12th rib is going up here so we make the next port in the middle nearer to the spine, and just at the edge of the muscles, and this is 4cm down from the lower part, lower border of the 12th rib so the incision will be about here. And now I take the 10mm port without a screw because we don’t move this port quite a lot so I put this in now and it’s a in a very low angle. The tip of this port is now touching the 12th rib as you can see, and now I go just beneath in this direction. On the other side, there will be nothing except fatty tissue. Now I have 2 ports under finger control, and now I take the third port and the third port is a blunt tip, which we always use. Just put that in, blow this up, and now we just connect the gas so now we have the 3 ports inserted for a typical surgery. The first important step is now to start with this port to look in and we take this one because on the back side of this port, my finger has created a very little space and we can have some view from the beginning. Put the camera in here and now we get the view inside that little hole here. Now you see some tissue just in front of us, and now I need a grasper. It’s a 5mm grasper, which I bring in from the lateral port, which we all know has been introduced under control and this is the first essential step in the beginning is to find my instruments.
5. Retroperitoneal dissection 09'29''
See now I have my instruments just somewhere in the depth and now I need to create the space. Now what you see first is the layer just in front of us. This is Gerota’s layer and we have to open this layer, and the kidney and the adrenal are behind this layer. And you see now that we are in the space where we have to go. Now we push down the fatty tissue like this, nothing else we are doing. It’s a 30-degree camera and in the beginning it looks up, see that the camera is looking 30 degrees upwards, and now you see a blue layer lateral. The blue layer is called peritoneum, and behind this blue layer, we have the spleen, we are on the left side, we have the spleen, somewhere there will be the stomach and the pancreas a little more down. So what you can see is that in a few minutes, you have created the space with the adrenal and the kidney must be situated. And we have to add a 3rd port, which is over here and the 3rd port has to be inserted a little more so that we don’t have it in front of this Gerota’s fascia so I do some more rapturing here and what we’re doing now is to put this first camera port, the camera to this medial port –the one that we are seeing now up there, and turn the camera so the view goes downward so now Dr. Sucik takes the camera and now I’ll take the next instrument: it will be the Ligasure®; so in my left hand, I have the grasper and in my right hand, I have the Ligasure®. Here I am with my 2 instruments. The first idea is to go to the kidney so the first thing we want to do is just dissect down to the kidney. The Ligasure® is on level 2. A while ago, I did some live surgery with this new device and I had some problems because I wasn’t on the right level. So what I first do is I just cut a little bit into the fatty tissue, which is somewhere behind the kidney and somewhere behind the adrenal gland.
6. Kidney upper pole dissection 12'43''
See we’re just finding the kidney now, the upper pole of the kidney or the backside of the kidney as you can see here. So the first step is look for where the kidney is. So now we’ll cut a little more of the fatty tissue, which is somewhere between the kidney and the adrenal gland but the plan is not to see the adrenal gland, I must stress this point again. Probably to give a little more anatomical ideas now: on the right side, the muscles here on the spine, this is the spine, and remember this 3D reconstruction we have had the spine medially to the adrenal gland and cranially to the kidney, here’s the kidney and the blue layer we saw in the beginning, with the spleen behind somewhere here. So as you can see, the idea is to do an en bloc resection of the tissue, which is now between these layers, here the muscles, here the peritoneum, and here the kidney. And the adrenal gland, of course, must be somewhere in this area. Again if the patient is very fat, and there’s a lot of fat behind the kidney or behind the adrenal gland, we move as much of the fatty tissue and push it downwards as much as you can do it. And I always say invest little more minutes to the mobilization of the kidney so that’s a real mobile organ. If you have a rupture in the capsule of the kidney, which may occur when it’s very much fixed to the fatty tissue, don’t care. There will be no bleeding afterwards. So we stay on the kidney a little more and the best way to do it is to stay on the peritoneum. I have one question, what happens if you open the peritoneum? Well, if you open the peritoneum, you will have some loss of gas, and the space will be a little smaller—meaning that surgery is not so comfortable but we never convert it because of this reason. Now when you look at the situation now, we will have, I think, quite a good exposure; the kidney now can be moved down and I do this with a lateral instrument. So the lateral instrument retracts and to show the rest of it, you know this is the fat around the adrenal and probably we have the kidney’s artery somewhere behind this tissue. But usually you have not to see that vessel and what we’re doing now again here is the spine you can see, and what we’re doing now, we go a little bit medially to look for the lower pole of the adrenal gland. The kidney’s surface that you’re pushing down on, that’s the anterior surface of the kidney, correct? Absolutely, the normal position is like this and this is the anterior surface, and you turn it a little bit and press it down. This is an essential trick for this type of surgery, especially on the left side because on the left side the adrenal is more often in front of the kidney, so you have to push it down a little bit.
7. Dissection of lower pole of adrenal gland 16'51''
So now we try to look where the lower pole of the adrenal is and it may be somewhere here. I see your movement with the Covidien device: is there any plans to have a device that articulates with more degrees of freedom? I don’t know about such a project, I’m not sure, and it would be very useful to have something also in combination with the robotic system, you know. So we go on and again to demonstrate the anatomy, here’s the peritoneum, and look down, the peritoneum is also here. The kidney is here, and of course, the adrenal gland is somewhere hidden in this fatty tissue. It must be there. So we’re looking for a small tumor and what we’re doing now, we go downwards from the spine anteriorly, this means downward, and cut the tissue here. So there can’t be any vessel going to the kidney now. And in case you have an upper pole artery, this upper pole artery—let me just explain this additionally, is coming from the aorta; the aorta is somewhere in the back here and it may cross here but by turning it down like this, the upper pole artery will not be in the field. So you can always spare that, I don’t have to dissect that. So now we try to find the lower pole of the adrenal. I can tell you that I can feel something already but we can’t see anything but that’s good because the idea is the en bloc resection, and there may be some vessels going up from the renal artery to the lower pole of the adrenal, they are dissected now. And again you see that we try to stay on the peritoneum. This is the peritoneum or Gerota’s fascia on the other side, so now it’s logical, everything is now up to this point and you can also take down this one. In the very beginning, we always started at the upper part of the adrenal gland but it’s much more convenient in a second to start from here. Now I think I take down this one. We didn’t see the size of the patient. Is this a skinny patient? Which is his BMI? It’s 26 or 27, something like this. So it’s a normal-sized European patient. Now there are some vessels crossing from the aorta to the adrenal. The adrenal must be somewhere in there. Now we cut down the small vessels, which are probably coming from the aorta. For those who have not seen this procedure with this approach, particularly in fatty patients, this is the most difficult part of the case because of that fat pad in that area that needs to be retracted to identify the renal vein in this region. I think in novices this can be the most difficult part of the operation. You make it look so easy.
9. Adrenal gland mobilization 24'02''
Now I have the vein in my hands and I can manipulate the adrenal. Now I stay on the vein here. And again, with the exception of the area where my grasper is, so I have not seen the adrenal gland. And it’s not necessary to see it. You go up a little bit. Now comes one of the tricks: as we have prepared in the right layer before, you just can do a blunt dissection from this layer, pushing down. Lifting up here a little bit. I can dissect here. The gland is in my hand somewhere. We just cut here. We lift up again. If it is fixed to the anterior part of the peritoneum, you may take the peritoneum with the specimen. And still I have the grasper on the vein. You can’t grasp the gland but you can grasp the vein. Now you see what we did. And now we go a little more along the phrenic one. And when I don’t have any more tension with the grasping device, I will switch to another area with my grasper, but I will go on like this for a few minutes. I can probably also do this in this situation: just push down the layer a little more. There are no vessels between. It is totally mobilized. Now I change my instrument. Grasp here in the fatty tissue. We come back to the same area. Cut this one, this one and this one too. So now we have a complete adrenalectomy. The stump of the adrenal vein is over here, the phrenic is going up here. In the back, we may see the splenic artery. You see some pulsations there? That is the splenic artery. Sometimes you can also see the splenic vein somewhere, I don’t know where exactly. This may also be the artery, because it’s turning like this. I still have it in my grasper as you can see. Now we take the bag.