Robotic right tumorectomy for schwannoma mimicking adrenal tumor

This video presents the case of a patient presenting with a 7cm tumor that was diagnosed as a non-secreting adrenal tumor. An adrenalectomy was proposed after the CT-scan analysis. A robotic approach was performed. It allowed for the resection of a tumor located between the kidney and the adrenal gland. The adrenal gland was preserved. Pathological findings helped to evidence a schwannoma.

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Robotic right tumorectomy for schwannoma mimicking adrenal tumor

Authors

D Mutter, M Vix, L Soler, J Marescaux

Abstract

This video presents the case of a patient presenting with a 7cm tumor that was diagnosed as a non-secreting adrenal tumor. An adrenalectomy was proposed after the CT-scan analysis. A robotic approach was performed. It allowed for the resection of a tumor located between the kidney and the adrenal gland. The adrenal gland was preserved. Pathological findings helped to evidence a schwannoma.

Classification

robotic

Keywords

Right adrenalectomy, robot, right schwannoma, right adrenal gland

Media type

Surgical video

Duration

13'00''

Publication

2012-04

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Subtitles

E-publication

WeBSurg.com, Apr 2012;12(04).
URL: http://www.websurg.com/doi-vd01en3606.htm

Robotic right tumorectomy for schwannoma mimicking adrenal tumor

1. Clinical case 00'22''

A 51-year-old male patient was referred to our department to undergo surgery for a right adrenal tumor. No endocrine secretion was noted. CT-scan helps to identify this 5 by 7cm tumor, which retracts the vena cava. Its contact with the adrenal gland is uncertain. It retracts the adrenal vein at its inferior pole. It is decided to perform a robotic-assisted resection.

2. Position of the robot 00'47''

The robot is placed at the patient’s shoulder. Three robotic arms will be used, one for the camera, and two arms for the operator. A fourth port will be used to lift up the liver, as well as a fifth port, 5mm in size, that will be used by the assistant to accommodate a suction device and to place clips.

3. Exposure and liver retraction 01'05''

The first operative step is a conventional one. After liver retraction, the first step consists in opening the sub-hepatic peritoneal fold. This helps to retract the liver and to access the resection area. The adrenal gland is indeed located underneath the right liver. It is mandatory to divide the triangular suspensory ligament of the liver in its external part. Here, only such a division helps to lift up the liver effectively and to bring it out of the operative field. In the present case, the epigastric port, which accommodated the liver retractor, plays an essential role in the exposure. The inferior border of the liver is freed so as to be retracted. The tumor’s resection area can then be approached safely. In the foreground, the tumor can be seen impairing the operative field. However, the use of a 30-degree scope as typically in robotic surgery, helps to solve the issue. Immediately, one can also see that the inferior and inferior medial pole of the tumor go beyond the vena cava. The peritoneum is incised all around the tumor in order to access the retroperitoneal space. This area is more vascularized than usual. As such, it is suggestive of a tumor situated potentially lower than a typical adrenal tumor. Internally, one is proximal to the attachments of the second duodenum.

4. Approach to the vena cava 03'11''

The six degrees of manipulation of the robot’s handle allow to find oneself systematically in an optimal position to take down the adhesions by means of monopolar cautery. The freeing of adhesions is carried out very progressively. A low power cautery set on 20 Watts is used. As usual in adrenal surgery, the objective is to approach the inferior vena cava. Here, the tumor lies inferiorly to the inferior vena cava, and only the freeing of the adhesions located on the tumor’s internal border allow to reach the inferior vena cava.

5. Superior dissection 04'01''

Dissection is carried out from the inferior border to the superior border of the tumor. No hypervascularization nor atypical vessels may be noted. The robot can be used thanks to the coagulating hook or also by using the posterior surface of the hook to achieve regular monopolar cautery. No other instrument will be needed at this time of the dissection.

6. Inferior dissection 04'41''

Dissection is carried out at the internal, inferior, and then superior pole of the gland respectively, hence achieving a circular dissection. The gland and the tumor themselves are never directly manipulated. Only their adjacent tissues are manipulated. Here, a mere traction at the level of the fat situated at the tumor’s inferior part helps to stretch tissues ideally. It also helps the robot to take down the different adhesions. The tumor is well delimited and represents the seat of a capsule. No inflammatory reaction around the tumor nor any infiltration of the adjacent tissues may be observed. Here, the superior pole of the kidney is clearly visible. The presence of a renal tumor is ruled out at this stage. The inferior dissection is carried out cautiously; as the gland follows a downward trajectory in contact with the renal vein, it must be identified with certainty. Dissection is then carried on towards the superior medial pole of the gland. It is indeed essential to identify the tumor’s resection margins. The vena cava is identified and its medial border can then be progressively and safely dissected.

7. Venous drainage of the tumor 06'11''

Attention is once again turned to the inferior pole of the tumor, which is very much in contact with the second duodenum as can be seen here. The second duodenum is retracted at the level of the genu inferius and the anterior part of the vena cava may now be approached. As the tumor is tightly wrapped around the vena cava, the dissection at the internal border of the vena cava must be carried out with utmost care. The inferior internal angle of the gland is progressively dissected, with the vena cava used as an anatomical landmark in the depth of the operative field. The dissection, which is carried out slowly and carefully, allows for the identification of a first vascular element proximally to the tumor. This vein is dissected progressively. It is located anteriorly to the renal vein. The dissection in the inferior dihedral of the gland is slightly more hemorrhagic. It is carried out very gradually by means of the robot, and changing instruments significantly impacts the operative time. The instrument used for retraction is kept open in order to prevent any damage. The posterior internal part of the gland is further freed. The progressive freeing of these adhesions will allow for the identification of the inferior draining vein of the tumor. It is prepared using the robot; the suction device and clips are used by the assistant to maintain good control over this vessel. Two clips are put in place in order to allow for a satisfactory hemostasis. Slight tension is applied, and the draining vein may then be divided. This allows for the freeing of the first part of the tumor’s inferior pole. The monopolar coagulation around the gland may now be carried on. In order to obtain optimal visibility, a gauze pad is introduced into the operative field – it is typical of laparoscopic surgery. This allows for the absorption of small blood effusions and for an improvement in the visibility of the operative field, as it increases brightness. The 8 degrees of freedom provided by the robot allow to pursue with the dissection in an optimal way. As can be seen here, it will be possible to identify the cleavage plane, the presence of which had been felt, between the adrenal gland and the tumor itself – the tumor does not expand into the adrenal gland. At this point, a tumor resection is decided upon, taking care to preserve the integrity of the adrenal gland. The resection will be carried out if the end of the dissection confirms that the tumor does not invade the adrenal gland.

8. Arterial vascularization of the tumor 09'23''

The tumor’s inferior pole is progressively raised, as the arterial vascularization of this tumor must be found. It is identified here, and originates within the renal artery. It directly reaches the tumor, which means it can be controlled, and then clipped safely. This will most probably allow to prevent small bleeders likely to hinder proper operative visualization. As for most arterial elements, three clips are put in place, two of which are on the side which will be preserved. Once again, the port held by the operator is the one that will be used for clip positioning – as for the robot, only 3 ports are used in this procedure. The artery is divided, and most of the adhesions around the tumor, that are located at the inferior pole of the adrenal gland, between the kidney and the adrenal gland, are freed. The dissection will now be carried out at the superior part of the tumor in order to reach the plane which had been identified, as being positioned in that plane will allow for the complete separation between the tumor and the adrenal gland.

9. Tumor extraction 10'58''

The tumor is free within the abdomen. The robot may now be removed from the operating table, as the tumor is introduced into an extraction bag and removed. The reintroduction of an optical port will allow the operator to control the good quality of the operative field; an extraction bag will be introduced through a 12mm port in order to safely extract the tumor once introduced into the bag. A control of the hemostasis of the operative field will complete the procedure. Pathological findings will confirm that this was an extra-adrenal tumor, a completely resected benign schwannoma with no capsular damage.