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Resection of a right para-adrenal ganglioneuroma: adrenal-preserving laparoscopic surgery

We present the case of a 43-year-old female patient in whom an adrenal tumor was incidentally found during a medical imaging study. As usually done, a 3D reconstruction of the lesion is performed in order to define the anatomical relationships and decide on the most appropriate surgical strategy. The excellent quality of the reconstruction will make it possible to envisage first the preservation of the adrenal gland and then the tumor resection during the intervention.

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Resection of a right para-adrenal ganglioneuroma: adrenal-preserving laparoscopic surgery

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D Mutter, L Soler, J Marescaux

摘要

We present the case of a 43-year-old female patient in whom an adrenal tumor was incidentally found during a medical imaging study.
As usually done, a 3D reconstruction of the lesion is performed in order to define the anatomical relationships and decide on the most appropriate surgical strategy. The excellent quality of the reconstruction will make it possible to envisage first the preservation of the adrenal gland and then the tumor resection during the intervention.

關鍵字

Resection, right para-adrenal ganglioneuroma, adrenal-preserving laparoscopic surgery

媒體類型

手術影片

期間

15'00''

刊物

2011-05

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, May 2011;11(05).
URL: http://www.websurg.com/doi-vd01en3237.htm

Resection of a right para-adrenal ganglioneuroma: adrenal-preserving laparoscopic surgery

1. Clinical case presentation 00'22''

We present the case of a 43-year-old female patient in whom an adrenal tumor was incidentally found during a medical imaging study. As usually done, a 3D reconstruction of the lesion is performed in order to define the anatomical relationships and decide on the most appropriate surgical strategy. If a right adrenalectomy is decided upon, a cleavage plane between the right adrenal gland and the tumor is identified on this reconstruction. The excellent quality of the reconstruction will make it possible to envisage first the preservation of the adrenal gland and then the tumor resection during the intervention. Here, the CT-scan corroborates the anatomical relationships, the position of the gland, and the position of the tumor in regard to the vena cava. As the adrenal vein is distal from the tumor, the lesion may be preserved.

2. Mobilization of the liver\'s lower pole 01'24''

The intervention is started as conventionally by the mobilization of the inferior pole of the liver. Indeed, whatever the option selected, it will be necessary to mobilize the liver cranially and to mobilize the right lobe in order to completely free the adrenal fossa.

3. Intraoperative augmented reality 01'46''

During the intervention, augmented reality is used. The 3D-reconstructed image is superimposed onto the operative image. This makes it possible to confirm the anatomical relationships that are considered in relation to the ones obtained during the preoperative imaging study. A few adhesions maintaining the second portion of the duodenum to the liver are taken down in order to have the duodenum completely outside of the operative field. From the beginning of the dissection, the tumor can be palpated. It is a soft tumor and the initial diagnosis was suggestive of an angiomyolipoma.

4. Freeing of triangular ligament 02'27''

The dissection must be carried out extensively until the triangular ligament of the liver is freed. Only the freeing of the triangular ligament will allow to retract the liver in order to provide sufficient view over the entire space to be dissected. This is all the more important in the present case as the junction between the tumor and the inferior border of the adrenal gland needs to be approached. The dissection is then pursued in a stepwise fashion alongside the tumor. The superimposition of the reconstructed image onto the operative image allows to precisely identify the anatomical relationships, the lateral border of the vena cava and the inferior pole of the adrenal gland. The dissection is bloodless and the excellent quality of images (also enhanced by the difference in color between the fat and the adrenal gland) allows to precisely identify the limit between these structures. Bipolar cautery is used to complete monopolar coagulation previously used to progressively free the anatomical structures. The right lateral border of the vena cava is freed in contact to the inferior border of the adrenal gland. The peritoneal reflection at the superior portion of the kidney is also opened in order to progressively mobilize the gland and especially the tumor cephalad. As seen preoperatively and as confirmed by the augmented reality, the tumor extends underneath and posteriorly to the vena cava. Here, a small accessory vein is ruptured during the dissection. It is immediately associated with a bleeding, which, if not that massive, impairs the dissection because of the alteration in colors. Bipolar cautery helps to control this small local hemorrhage. It is essential to minutely control the whole of these small veins in order to achieve a perfect quality of vision and carry out the dissection while preserving the adrenal gland in contact to the tumor. It is also essential not to cause any capsular effraction as this tumor may be either a sarcoma or a connective tumor. Dissection is continued in contact to the vena cava in order to progressively free the tumor from the retrocaval space. Neither inflammatory reaction nor adhesions nor vena cava invasion may be observed. This is suggestive of the benign nature of this lesion. Consequently, this also leads us to carry on the dissection laparoscopically. One of the objectives of this minute dissection is also to preserve the capsule of the tumor in order to avoid any tumoral dissemination in case of malignant lesion.

5. Division of peritoneal reflection of the superior border of the kidney 05'41''

The peritoneal reflection at the superior border of the kidney will be opened entirely. Once again, the lesion is progressively circumscribed in order to free it of its attachments. The adhesions along the superior border of the kidney are dissected in a stepwise fashion using monopolar cautery. The bipolar forceps is used for complementary coagulation, if need be. It is used as a retractor. It is not used to grasp the tissues but to exert a slight traction onto them. A complementary coagulation through the use of a Ligasure® vessel-sealing device is particularly useful in this dissection area. Anatomical landmarks are well visible here, and particularly the inferior anatomical landmarks, which are the superior part of the right renal vein. The dihedral angle between the renal vein and the vena cava is well identified. The tumor lies in contact to the vein. The Ligasure® device helps to perform the dissection in contact to the vena cava and posteriorly to the tumor. Once again, the dissection is carried out in contact to the adrenal gland and at this stage, no resection nor adrenal dissection is undertaken. The mobilization is progressively performed using the Ligasure® device at the internal and the inferior portion of the lesion, which is progressively extirpated. Following this exposure, one can see that there is no posterior extension of the tumor and no posterior invasion. Once again, this is suggestive of the benign nature of the tumor. As such, a total resection of the lesion may be envisaged without any capsular effraction.

6. Completion of lesion freeing and resection 07'59''

The avascular structures are freed using monopolar cautery. The small potentially vascular structures will be controlled by the use of the Ligasure® device. The inferior medial pole of the lesion – most probably containing the inferior adrenal artery – is controlled with the Ligasure® device. Dissection is carried out in contact to the paravertebral muscles and to the superior border of the kidney. The lesion is freed in a stepwise manner. Coagulation provided by a Ligasure® device is truly perfect. It allows for the sealing of tissues and provides a clear view of the anatomical landmarks as well as a secure hemostasis. The most posterior part of the lesion can be freed. This will facilitate the freeing of the superior pole of the lesion off the adrenal gland. The resection is performed in contact to the paravertebral muscular plane. The inferior border of the tumor is freed totally. Its posterior retrocaval portion is also freed entirely. The peritoneal fold is the only anatomical structure that is still present at the inferior pole of the tumor. The 30-degree optical system is useful for the exposure and the dissection of the most distal and the most posterior structures, and especially so because of the size of this lesion. The attachments at the inferior pole of the liver are taken down, but once again, they are freed at the inferior pole of the adrenal gland. The objective is to mobilize and to completely lift up the tumor in order to make sure that there is no persistent adrenal extension. The very posterior peritoneal fold cannot be reached with the instruments placed in such a position. The Ligasure® device is therefore switched to the operator’s left hand in order to be used in a most appropriate axis to help with the dissection. It is essential to emphasize that the tumor is never grasped nor manipulated with a forceps, which might cause a capsular effraction. As the entire lesion has been freed, a mere retraction using a small peanut swab helps to free the tumor from the inferior pole of the adrenal gland. Consequently, the posterior adrenal lesion will be resected very progressively and safely by preserving the healthy adrenal gland. The lesion is now completely freed from the adrenal gland. Its few remaining attachments are freed.

7. Vascular supply coming from aorta 12'06''

This lesion is supplied by a direct vascular pedicle coming from the aorta. Such vascular pedicles are surrounded with lymph node structures and it is necessary to perfectly control their hemostasis. They are small arteries directly originating from the aorta. Their course is very short and they may bleed postoperatively. Even though the Ligasure® device provides an excellent control of these arteries, special attention will be paid at the end of the intervention to rule out the risk of any secondary bleeding. Here, the tumor has been freed totally, without any capsular effraction. The paravertebral muscles have been skeletonized. No remaining tissues that may originate from the tumor are left in place in the adrenal fossa.

8. Control of dissection area 13'32''

The dissection area is controlled one last time. Augmented reality helps to confirm the position of the vascular structures, the vena cava, the renal vein, and the inferior adrenal artery. A small hemorrhagic oozing coming from the previously controlled artery leads us to place a clip to achieve a perfect final control of this region. The tumor is therefore totally free. The resection area is entirely dry.

9. Specimen extraction 14'04''

The specimen will be introduced into an extraction bag as usual. It will be extracted out of the abdomen without any contact to the wall. The objective is to preserve the wall from any potential tumor graft. The control of the specimen is performed. The pathological examination confirms the existence of a para-adrenal ganglioneuroma, completely resected and without any capsular effraction. The specimen measures 8 by 6cm. Augmented reality is used on the specimen at the end of the intervention.