Retroperitoneal right adrenalectomy: single port approach

Laparoscopic adrenalectomy has been shown to be safe and effective for a variety of benign adrenal tumors. The extraperitoneal approach with a minimal access procedure provides direct access to the adrenal glands without interfering with intraperitoneal organs. This video shows a live demonstration of an extraperitoneal access using a single port technique.

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Retroperitoneal   right   adrenalectomy:   single   port   approach

Authors
M Walz, J Marescaux
Abstract
Laparoscopic adrenalectomy has been shown to be safe and effective for a variety of benign adrenal tumors. The extraperitoneal approach with a minimal access procedure provides direct access to the adrenal glands without interfering with intraperitoneal organs. This video shows a live demonstration of an extraperitoneal access using a single port technique.
Classification
single port, live recorded
Keywords
Retroperitoneal right adrenalectomy, single port
Media type
Duration
29'00''
Publication
2011-11
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en


E-publication
WeBSurg.com, Nov 2011;11(11).
URL: http://www.websurg.com/doi-vd01en3499.htm

Retroperitoneal   right   adrenalectomy:   single   port   approach

2. Port insertion 01'53''
Usually after the first step, I take the gun, you know, that’s the Visiport™. But today we don’t have so I have to go in with my scissors to the muscles just to find. Now I think I’m inside with my instrument, with the scissors in the retroperitoneum. Just feel that you pass the layers of the fascia. Now I think that I’m inside now and I’ll bring in the first port. And the first port is a standard 5mm Storz port with a screw on it, see that screw? And I just try to bring this in now. I think that the port is in the right place now. And now we put the gas on. And the trick is as you may see on the back of the patient that the pressure goes up to 30 so it’s very high pressure. Now I bring in the camera and indeed I can see something. You see the port is somewhere and probably very important and we should come back to this now and show that I use a 30-degree, 5mm camera with a special adapter of the light cable. See that the light cable is not going up just in a 90-degree angle, it’s going down or to my hands. So I can take that in my left hand now and so when you look inside, I’m rather happy because in front of us you have these fibers and this layer down there is Gerota’s layer from the back. And this is exactly where we have to go. Medially, there must be the spine; somewhere lateral, there must be the liver but just in front of us is Gerota’s layer. This is this one. And now we have to go behind because behind is the fat around the adrenal and the kidney and so we have to go behind, this means that we have to go in, and this is the point.
4. Identification of landmarks 05'25''
As explained in the beginning, it’s very important to know that the adrenal gland is near the spine so the direction is from lateral to medial and this is how the camera is working now, and you see just in the back you have the muscles here and we may have the kidney down here as you can see. And so the kidney is the first landmark or the second landmark and the other landmark is of course the spine, and now we try to create a little more space now just with the camera. So it’s an extraperitoneal approach so we are outside the peritoneum. We don’t see the peritoneum except the area where the liver will be covered by the posterior peritoneum. Now 30 degrees means that I can change a little bit the angle. And the difficulty is sometimes to create the space because of the dimensions of the patient but at the moment everything looks nicely. And again I have to sharpen a little bit. I think we have the kidney down here. And as you have just seen by Luc Soler who showed you where the adrenal gland is, it’s somewhere in front of the kidney so we have to do a bit of dissection in front of the kidney. So now we are in the area of the kidney here, of the adrenal gland, which will be down here. And we have created the space just with the camera. There’s no second instrument up to now. The second instrument will be introduced by a special port and this special port is this one. And now you see that I’ll show you the introduction of the second port parallel to the first one and lateral in the incision of the skin. And now my feeling is I should be inside. Sometimes you can hear that because the gas loss is here. We hear that the gas is coming out now so I know I’m in the same space though I did not see it as the first port is. Put in a grasper, and you see the grasper is coming inside. So we are in the same area. So now I take the grasper a little more to create a little more space and to identify all the structures. And the trick is in retroperitoneoscopic adrenalectomy is first of all push down all the fat as much as you can do. Now we have the third landmark. As you remember the kidney is somewhere down here. It’s over there. The spine is on this side, and on the other side we now have the peritoneum behind the right lobe of the liver—this is the blue layer up there, down there. And there’s no doubt that the adrenal gland must be between here, here, and here. And it’s very attractive to show or to see the upper pole of the kidney first so don’t look for the adrenal gland, just look for the upper pole of the kidney. It’s always been the strategy we have followed for so many years and now what we have to do, we have to dissect. The patient is not too fat as you can see but in this case, you can’t see the adrenal gland just in the beginning. In very slim patients, you will be able to see the adrenal gland. Just now, probably I can show you a little. Let’s look if it’s possible or not. But the adrenal gland is at the highest point of course. But usually you don’t have to search for it because it’s always there. I think this may be adrenal tissue here. Colors are a little bit different as compared to the fat around. But we don’t care about the adrenal first.
6. Vena cava identification 11'47''
We’ll see the cava in a few minutes and it’s a surprise that we have never had with any type of pressure any thrombosis in any of our patients. I can’t explain exactly but what we learn is from hemodynamics, that is that the cardiac output is increasing more in the prone position that in the supine position. And even with this high pressure, we don’t have a reduction of the cardiac output in this patient. So they are very, very stable. Usually for the Conn’s, we don’t need a central line. We have one in this case but usually you don’t need that, and we never put in a urinary catheter in this patient because it’s not necessary to do this. So what you see is I’m just dissecting the upper pole of the kidney, and it’s all blunt dissection. You see the best layer to stay is the peritoneum, which is this one again. The right lobe of the liver is behind here. And what I try is you see my instrument retracts and dissects. So this is a double function because it’s only one-hand surgery. Of course, it’s much more convenient to have more than one port but just to demonstrate that it’s possible to do it like this. Usually, we don’t put in another port and usually we don’t put in another instrument. On the left side, the dissection is a little more difficult because usually the adrenal gland is a little more in front of the kidney so this means basically that you have to do a little more retraction on the kidney, and therefore it may be sometimes helpful that you put a third instrument in, and usually you put this third instrument in between the first and the second one and just without a port. And this has only one function, and you can imagine this function will be just like this to retract the kidney. If you retract the kidney like this, you will have a slightly better exposure of the structures, but usually it’s not necessary. Can you explain to the audience your experience in laparoscopic adrenalectomy and also in the one trocar approach? We started this project 3 years ago as a reaction to the idea of removing the adrenal gland using the NOTES technique, and it was Jacques who motivated me a bit when he said once that I no longer was a creative surgeon, and therefore I decided to do something else. And this is what happened that we did the posterior approach with one incision only. The program started in the beginning or the end of July 2008 so about 3 years ago now, and I can tell you that it was a big surprise to me in the beginning that it worked and I wouldn’t have expected it. What you can see now just coming back to the case that all the tissue that is now in front of us is adrenal tissue and the para-adrenal fatty tissue. And the strategy usually is to do an ‘en bloc’ resection of everything.
7. Adrenal gland dissection 15'53''
So just to try to stay in the right plane and the right plane is again the peritoneum here. We have some more adhesions here--- I just cut them down, I think, like this. What we know is that the vessels from the adrenal gland are coming from 2 areas. One area is the renal vessels, which are somewhere down here. Usually, you don’t have to look for these vessels. Usually for adrenal surgery, you don’t have to see the renal vein or the renal artery. But sometimes in cases when the tumor is very low, it may be necessary. But usually it’s not necessary. What you see here is a few branches of vessels here coming from downwards—this means they may come from the kidney’s vessels. There are other vessels, which are just crossing again from here to here; again this is the adrenal; again this is the spine, and these are the vessels crossing behind the vena cava, and those of you who have experience may have seen the vena cava already, it’s just down here. The blue big is just down here. So it is again to demonstrate that there is only very little risk that you run into the cava, because it’s such a big vessel, and you see that the attraction of the posterior approach again is that you come from the back and this means that difficult vessels, which are crossing from medial to lateral behind the cava are absolutely no problem for this approach. So I grasp this now and cut it down. And if you can lift the tissue like this, you haven’t grasped the cava. So again we now have a little more approach to the inferior medial part of the adrenal gland. We must agree that we haven’t seen adrenal tissue now in this area and this is the idea that probably you never see adrenal tissue by dissecting the adrenal gland from the surrounding structures. What I wanted to show you is that I just dissected the tissue from here to here and that you have the arterial stump now here. See this may have been the main adrenal artery, see that? I can tell you now something about the history of this approach, which dates back to 1992-1993 when the first papers came out about adrenalectomy and they were the very first papers about the laparoscopic technique. And they were disappointing for me because they demonstrated that the mean operating time was about 5 hours in the first 5 papers. And there is a report from Japan, which demonstrated that they needed 9 and a half hours for a 2cm Conn’s. At the same time, we did posterior open surgery, which is very fast, but not very precise. It’s a very fast thing and from skin to skin, we needed about 45 minutes up to one hour, no more than this, and on the other side, we had laparoscopic surgery with 5 hours in duration, and then we decided that we should try this approach and we succeeded with the first case. We had done one pig before but we did not succeed because the anatomy of the pig is much more difficult, and so in 1994, we had our first adrenalectomy by this approach, and we continued by this, and the first surgery, the very first case without any experience, without any video, without any education before, it was 2 hours and 45 minutes, and it took us one hour to retrieve the specimen because we hadn’t had any good bag for this first surgery so we put in gloves and things like that. We managed the case in about 2 hours and then one hour more for the retrieval of the tissue. And so my impression was from the very early beginning that this approach was much more logical. What we did not use in the beginning were high pressures because everybody used 12mmHg, and we also did the same. And the problem with fat patients is that you don’t get a good space. We’re using 12mmHg but as you can see in this case, we went up to 30, and now we have a fairly good space. See the cava here from the back. See the adrenal gland somewhere here and you can just see the adrenal vein is coming here and so the pressure is one of the keys of the whole thing. And the pressure always allows us to do safe surgery. On the other side, as you can see, the field is rather dry, we had some oozing from some tissue in the beginning but I didn’t care a lot about that because as long as you have only little venous bleedings, you don’t need to do anything, just wait and it’ll be blocked immediately. For artery bleeding, as you know, it’s the same in laparoscopic surgery. Just put a gauze on and wait a bit and that’ll stop automatically. So what you can see now is that we have the adrenal vein in front of us. For the adrenal vein, I always use the Ligasure®. I never clip, and there’s a very simple argument. I also learnt very nicely at the Strasbourg courses that all dramatic bleedings in adrenal surgery are caused by removal of clips, and if you have no clip inside, you can’t remove any, and therefore we decided after we had the feeling that it was really safe what we were doing, just to cut the adrenal vein with the Ligasure®. We started this in 2006 and there are a few hundred cases now, and there is no bleeding in any of these cases, even not during surgery or in the evening or any time later. So I feel very comfortable with this. Please remember that the problems of dissecting vessels with the Ligasure® are not the veins. The problems are the arteries, and if you have a big artery, you must be very careful. The big veins, even the splenic veins are doing fine, and therefore I feel very much comfortable with this. See now it’s nearly impossible to see where we dissected, it’s here. So now it’s a surprise that this patient has a fixation of the adrenal a little bit to the liver. But these adhesions are rare. Also I have a nice story. About 15 years ago, I had to review a paper from Taiwan. There was one point where they said, well, we have an adhesion of the adrenal gland to the liver (as in this case) in about 20 to 30% of our cases. So I had to review and I wrote down I had never seen that in my first and early experience. That’s fixed like this in this case today. One year later, I saw the first patient from the Philippines in our hospital. And this patient had a very wide fixation of the adrenal gland to the liver so it may have been due to the fact that patients come from different regions of the world and so this is an anatomical detail, which in middle European patients is rare. In Caucasian patients, it may be rare but others may have that. So this is my experience with the cases we had up to now.