Right laparoscopic adrenalectomy
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Right Laparoscopic Adrenalectomy. University of Kentucky Minimally Invasive Surgery Elective. Indications for Laparoscopic Approach. Adrenocortical tumors related to: Cushing’s Disease Conn’s Disease Virilization of females Feminization of males. Pheochromocytomas

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Right Laparoscopic Adrenalectomy

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Right Laparoscopic Adrenalectomy

University of Kentucky Minimally Invasive Surgery Elective


Indications for Laparoscopic Approach

Adrenocortical tumors related to:

  • Cushing’s Disease

  • Conn’s Disease

  • Virilization of females

  • Feminization of males

Pheochromocytomas

Incidentalomas (of sizes greater than 3-4 cm)


Contraindications for Laparoscopic Approach

  • Adrenal tumors greater than 8-10 cm

  • Adrenal Carcinoma

  • Intracranial hypertension and coagulation issues

    • These are contraindications in all laparscopicsugery.

  • Surgical history of kidney of liver

    • This is due to an increased risk of adhesions, which would not allow for a transperitoneal approach to be utilized.


Procedure Positioning (Patient)

  • The patient is placed in a left lateral decubitus position, with the table flexed at the midline. This opens up the operating field.

  • A cushion is often placed under the left flank of the patient.

  • The legs of the patient are flexed in order to avoid neuropathy of the lower extremities.


Procedure Positioning (Surgical Team)

  • Both the primary surgeon and the assisting surgeon stand on the abdominal side of the patient.

  • The assisting nurse stands opposite of the surgeons.

  • The anesthesiologist stands at the head of the table.


Procedure Positioning (Equipment)

  • The anesthetic equipment is placed at the head of the bed.

  • The instrument table is placed at the foot of the bed next to the nurse.

  • There are monitors on both sides of the operating table.


Procedure Positioning


Port Placement

  • There are four 10 mm trocars utilized in the right adrenalectomy.

    • There is one placed at the anterior axillary line, under the costal margin.

    • Another trocar is placed at the mid-clavicular line.

    • There two remaining trocars are placed one either side of the previously placed trocars, still parallel with the costal margin.


Port Placement


Instruments Required

  • 30 Degree Laparoscope

  • DeBakey Grasper

  • Harmonic Ace curved shears

  • Laparoscopic scissors

  • Hook Cautery (sometimes used instead of Harmonic)

  • Clip Applier

  • Suction-Irrigation Device

  • Extraction Bag


Procedure

  • Mobilization of the liver:

    • The liver is retracted with the use of a snake retractor. When doing this, compression of the gallbladder should be avoided.

    • Once this has been accomplished, the subhepatic peritoneum is dissected. This will free the triangular ligament of the liver.


Procedure

  • The dissection of the subhepatic peritoneum should allow for the surgeon to see the vena cava and the un-dissected adrenal gland behind it.

  • Identification of the main adrenal vein:

    • The medial aspect of the gland should dissected towards the vena cava.

    • The right main adrenal vein should be seen emptying into the vena cava.

    • Typically, 3 clips are applied, 2 distally and 1 proximally.


Procedure


Procedure

  • In approximately 10% of cases, there is an accessory adrenal vein that also requires ligation.

  • If present, it can be seen connecting to the right suprahepatic vein.

  • It should also be clipped and ligated.


Procedure

  • Identification and ligation of the adrenal arteries:

    • First, the middle adrenal artery should be ligated. It should be seen originating from the aorta.

    • Next, the superior adrenal artery should be ligated. The adrenal gland should be retracted caudally, making it easier to observe this artery stemming from inferior phrenic artery.

    • Last, the inferior adrenal artery should be ligated. In reflecting the adrenal gland rostrally, this artery can typically be seen branching off of the renal artery.


Procedure

  • Once all arteries and veins have been clipped and ligated, complete dissection of the superior, medial, and inferior portions of the gland can take place.

  • Following this, an extraction bag is utilized to carefully remove the gland from the patient.


Potential Complications

  • Damage to Liver

    • Such injury can occur during retraction or during dissection itself.

  • Damage to Vena Cava

    • This is the leading cause of conversion to open surgery.

    • If the lesion is less than 2 mm in size, then it is quite possible that compression and coagulating agents will suffice.


Post-operative Care

  • The patient may ambulate on the day of surgery.

  • By the night of the surgery, the patient is allowed fluids.

  • On the first post-operative day, the patient is allowed to consume solid food.

  • Release from hospital typically occurs on the 2nd or 3rd post-operative day.


Difficulty of the Procedure

  • Because of the retroperitoneal location of the adrenal glands, dissection of peritoneum and other fascia often account for the majority of operation time.

  • This extensive dissection can be a hassle. To compound the problem, a survey discovered that, on average, general surgery residents only received exposure to 1.5 adrenalectomies during their residency.


Differences of Right and Left Adrenalectomies

  • Right adrenalectomies tend to considered more difficult than left adrenalectomies.

  • Common thoughts that support this:

    • Retrocaval location of right adrenal gland

    • Difficulty of handling the short main adrenal vein that drains into the vena cava.


Study Concerning Differences in Right and Left Adrenalectomies

  • To investigate this matter, a retrospective study of 163 laparoscopic adrenalectomies was performed.

  • The study was performed over an 8-year period, following 27 surgeons at 9 Southern California Kaiser Permanente Hospitals.

  • 109 of the surgeries were left adrenalectomies, while 54 were right adrenalectomies.


Outcomes

  • Blood Loss

    • The average estimated blood loss of the left adrenalectomies was 113 mL, ranging from 2 to 3000 mL.

    • The average estimated blood loss of the right adrenalectomies was 84 mL, ranging from 10 to 700 mL.

    • This was shown to not be statistically different.

  • Procedural Time

    • This however, was statistically different.

    • Procedural time from left adrenalectomies was, on average, 31 minutes longer than right adrenalectomies.


Plausible Explainations:

  • Proximity to tail of pancreas

    • There was an 8% rate of distal pancreatic injury reported.

  • Complexity of splenic vasculature

  • Required dissection of left renal hilum

  • Less mobilization is required for right colon than for the splenic flexure.


Retroperitoneal Approach?

  • In a study comparing retroperitoneal approach with the transperitoneal approach, it was found that the operation time for the retroperitoneal approach ranged from 290 to 330 minutes.

  • In comparison, the transperitoneal approach averaged 140 minutes in duration.

  • Why?

    • It was found that maneuvering of the surgical tools proved difficult because of a smaller operating field.

    • In addition, less of the adrenal gland is exposed in this approach.


References

  • Laparoscopic Right and Left Adrenalectomies: Surgical Endoscopy. (http://www.ncbi.nlm.nih.gov/pubmed/8703150)

  • Differences in Right and Left Adrenalectomies: Journal of the Society of Laparoendoscopic Surgeons. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3041033/)

  • Laparoscopic Right Adrenalectomy:WebSurg. (http://chapters.websurg.com/technique/index.php?doi=ot02en211&s=12&k=2)

  • Images from Adrenal Surgery. (http://www.endocrinesurgery.net.au/laparoscopic-adrenalectomy/)


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