Laparoscopic left adrenalectomy for Conn's adenoma: three trocar technique

Conn's disease is a condition in which the adrenal glands produce too much aldosterone. Prevalence estimates for Conn's syndrome is about 0.03-1.2% of the population with hypertension. Many patients with Conn's disease have a high blood pressure that is difficult to control. This increases the risk of stroke, heart disease and kidney failure. When Conn's disease is caused by a tumor (benign adrenal adenoma), surgical resection is advised. This video demonstrates the case of a woman presenting with Conn’s disease. The preoperative work-up demonstrated a tumor located on the left adrenal gland. The patient presented an elevated aldosteronemia and the CT-scan demonstrated a 2cm left adrenal tumor. The patient is placed in a full lateral position, on the right side.

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Laparoscopic left adrenalectomy for Conn's adenoma: three trocar technique

Auteurs

D Mutter, L Soler, J Marescaux

Résumé

Conn's disease is a condition in which the adrenal glands produce too much aldosterone. Prevalence estimates for Conn's syndrome is about 0.03-1.2% of the population with hypertension.
Many patients with Conn's disease have a high blood pressure that is difficult to control. This increases the risk of stroke, heart disease and kidney failure. When Conn's disease is caused by a tumor (benign adrenal adenoma), surgical resection is advised. This video demonstrates the case of a woman presenting with Conn’s disease. The preoperative work-up demonstrated a tumor located on the left adrenal gland. The patient presented an elevated aldosteronemia and the CT-scan demonstrated a 2cm left adrenal tumor. The patient is placed in a full lateral position, on the right side.

Catégorie

new techniques

Mots-clés

Laparoscopic left adrenalectomy, Conn\'s adenoma, three trocar technique

Type de vidéo

Vidéo chirurgicale

Durée

15'51''

Publication

2009-06

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Jun 2009;9(06).
URL: http://www.websurg.com/doi-vd01en2558.htm

Laparoscopic left adrenalectomy for Conn's adenoma: three trocar technique

1. Introduction 00'17''

We report the case of a woman presenting with a Conn’s disease. The preoperative work-up demonstrated a tumor located on the left adrenal gland. This patient presented an elevated aldosteronemia and the CT-scan demonstrated a 2cm left adrenal tumor. The surgical procedure is performed as usual.

2. Patient positioning 00'45''

The patient is placed in a complete lateral position; here for a left adrenal gland, we place the patient on the right side.

3. Freeing the adhesions 01'03''

The surgical procedure starts with the freeing of several adhesions of the left colic angle to the parietal wall. This helps to have an access to the inferior edge of the spleen. Dissection is conducted progressively. The first step of the procedure, and what is probably the key step of the procedure, is a complete mobilization of the spleen.

4. Spleen mobilization 01'39''

The mobilization of the spleen, together with the tail of the pancreas, requires the freeing of the lateral attachment of these two elements to the left parietal wall: this will allow the freeing of the adrenal area. This dissection is performed progressively, using either an ultrasonic dissector, hook, or scissors with monopolar cautery. With a very gentle retraction of the spleen, we can completely mobilize these elements. The left angle of the colon is sometimes lowered in order to have a better access to the spleen. The freeing of the spleen must be performed very high until identification of the stomach. In fact, this freeing has the objective to allow a complete and free mobilization of the spleen in the right part of the abdomen without any mobilization. As we see here, the operator is working with one retractor and one dissection trocar, and these two allow to free the spleen. The spleen is not manipulated, thus avoiding any tear of the capsule. Some small vessels must be carefully coagulated in order to avoid any bleeding. The pancreatic tail can be identified very early.

5. Dissection along Gerota’s fascia 03'10''

Identification of the free space along the Gerota’s fascia below the pancreas must be identified very early in order to avoid performing the dissection between the pancreas and the spleen.

6. “En bloc” mobilization of the pancreas and spleen 03'33''

Hereby, the mobilization of the pancreas and the spleen will be performed in an ‘en bloc’ fashion, without separating these two elements. Dissection along the Gerota’s fascia is a really avascular plane; this is performed by progressively coagulating all the collagenous and fibrotic attachments between these two elements. No bleeding must occur during this dissection if it is performed in the correct plane. Dissection uses a simple grasper to present the elements and the tip of the scissors, allowing coagulation and section of the coagulated elements. This is done very gently in order to avoid any bleeding during this manipulation. The objective of this dissection is the clear identification of the splenic vein.

7. Splenic vein identification 04'37''

The identification of the splenic vein is a key landmark to allow the identification of the main adrenal vein. In fact as can be seen here, the splenic vein has to be dissected along 5 to 7cm before opening the Gerota’s fascia. The opening of the Gerota’s fascia will allow to identify the renal vein and the main adrenal vein. To free completely this operative space, the spleen is always dissected on its upper edge allowing it to be retracted laterally and to open the operative space of the adrenal gland. Here we see the opening of the Gerota’s fascia, which is performed very carefully and progressively always using monopolar cautery. The monopolar cautery is at a very low level, about 20 Watts, in order to avoid any diffusion of the heat and to avoid any coagulation of the surrounding elements.

8. Main adrenal vein identification 05'50''

Performing this low dissection will allow to get the identification of the main adrenal vein. Here we see clearly that the main adrenal vein is identified after following the splenic vein.

9. Renal vein identification 06'07''

The main adrenal vein is progressively dissected on its right and left border until identification of the renal vein. The accessory adrenal vein is always identified on the left side and is sometimes controlled at its origin or a little bit later. Here, after very clear identification of the renal vein, the main adrenal vein can be dissected completely. This dissection is done using monopolar cautery in order to avoid bleeding behind the main adrenal vein. Very small vessels surround this vein and can bleed during the application of the clip. Sometimes, cautery is a little bit more difficult due to the lack of perfect exposure. In this case, this is due to the fact that the procedure is performed with 3 trocars. In many cases, we can avoid on the left side the positioning of a fourth port as the exposure of the elements doesn’t represent a major challenge.

10. Main adrenal vein division 07'25''

When the vein is completely and well controlled, two clips are applied on the side of the renal vein; one clip is applied at the level of the adrenal gland, and the dissection can be carried out by complete dissection of the further vascular elements. After division of the main adrenal vein, the next step is the medial adrenal artery.

11. Medial adrenal artery identification and division 07'54''

It is identified just below the origin of the accessory adrenal vein. For didactic reasons, this artery is controlled with clip application. It could be controlled with bipolar cautery, with the Ligasure device, or with an ultrasonic dissector. Here, one clip is placed on each side and the space between the gland and the muscles behind the gland are progressively dissected. The dissection is performed from caudad to cephalad until identification of the diaphragm and its muscle.

12. Upper adrenal artery identification and division 08'39''

At the upper edge of the gland, the upper adrenal artery is then identified. It is dissected, controlled again with clips and divided. The division of the adrenal artery represents the major step of the upper dissection. When this is achieved, the gland is freed on its lateral and upper side. The next step will be its freeing on its external and inferior borders. We see that the internal dissection of the gland is completed. The freeing of its upper edge will be completed from the left to the right as the exposure is not so good from this side.

13. Accessory medial adrenal artery dissection and division 09'43''

An accessory medial adrenal artery is also identified behind the previous one and this is again controlled after clip application. This is an uncommon artery as usually we only identify one artery on this side. We see very clearly the free internal border of the gland. Further dissection will be conducted between the adrenal gland and the kidney. The objective is to identify the inferior pedicle and to free the external and inferior parts of the gland. The hook is used to open the peritoneal reflection. The main difficulty in adipose patients is to identify the plane between the kidney and the gland. Here this plane is opened using the hook and the kidney is very clearly identified. The dissection is conducted with monopolar cautery. As usual in this plane, we can identify an accessory adrenal vein. This vein joins the perirenal fat. The posterior layer of the gland is freed and the dissection is conducted from this external part to the previous internal dissection area in order to identify the inferior adrenal pedicle. The dissection is conducted very cautiously at this level, especially in this type of patient because in several cases we can identify very clearly a superior renal artery. This superior renal artery has to be preserved in order to avoid postoperative renal hypertension in this patient. To identify this artery, the fat is very progressively opened with a very clear identification of the tissue.

14. Upper and inferior adrenal artery identification 11'57''

Here in this patient, we see very clearly this accessory upper renal artery that is identified here in the lower part of the operative field.

15. Inferior adrenal artery division 12'09''

This adrenal artery is preserved and the clips of the inferior adrenal artery are placed very close to this artery, preserving its function. The inferior adrenal artery can be cut and this will allow the gland to be lifted very gently using a simple peanut swab. The posterior vein is identified at this level and, in order to avoid bleeding, it is controlled by clip application. This represents the control of the main vascularization of the gland. Sometimes, on its posterior edge at the end of the dissection, another little artery can be identified joining directly the inferior edge of the gland. Here again, it is the reason why the dissection will be conducted very progressively.

16. Final dissection 13'12''

The final dissection is conducted using mainly monopolar or bipolar cautery. All the little elements must be coagulated in order to avoid postoperative bleeding. The gland is never manipulated with the grasper, but only gently retracted thanks to a peanut swab. Here we can see that a very little accessory pedicle is controlled by clip application and then cut. The freeing of this little pedicle and dissection is conducted again with monopolar cautery, which will allow a complete freeing of the gland. The landmark of the liver is very well identified, the internal edge of the dissection is completely free and the final dissection of the gland is only a dissection of some little fat. Here we see the use of bipolar cautery in order to allow a very safe control of all the elements and in order to avoid any postoperative bleeding. In fact, in this patient we do not place any postoperative drain. We see the dissection of a little vein that is coagulated and the gland is completely free in the abdomen.

17. Gland extraction 15'04''

The gland will be extracted from the abdomen after insertion into an extraction bag as we usually do. This bag is extracted through the incision receiving the camera throughout the procedure. At the control, the specimen still presented a 2cm little nodule at the inferior edge of the gland. This is well identified here.