Absolute indication for conversion: right adrenal carcinoma

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Absolute indication for conversion: right adrenal carcinoma

Authors

Keywords

tumeur volumineuse,VCI et aorte envahies,reconstruction 3D,simulation préopératoire,conversion

Media type

Surgical video

Duration

05'00''

Publication

2004-12

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E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1580.htm

Absolute indication for conversion: right adrenal carcinoma

1. Virtual reconstruction 00'15''

This video will demonstrate conversion during laparoscopic right adrenalectomy. The case is that of a 37-year-old woman with a right adrenal tumor. Here we have the CT-scan of the patient showing the tumor measuring 6cm by 8cm in size. 3D reality models are superimposed onto this image in order to demonstrate the pathological anatomy. As evident, you can see that the tumor is extending between the vena cava and aorta crossing the midline. Here from a superior angle, the proximity of the tumor to the major vessels can be appreciated. The addition of other organs further facilitates the surgical planning. As you can see, the liver is larger than normal in this patient. Now to the surgical approach: the transparency facilitates choosing the correct surgical approach.

2. Trocar placement 01'15''

The patient is placed in a left lateral decubitus position. Augmented reality by superimposition of virtual reality and virtual instruments demonstrates the trocar positions. Trocars used are not conventional. Two trocars are necessary for the retraction of the liver as shown.

3. Dissection 01'37''

Now to the laparoscopic view: following adequate exposure, the peritoneum is incised over the anterior aspect of the tumor as shown. The incision is extended in order to expose the structures around the tumor. The vena cava has now come into view to the right of the screen. This virtual reality reconstruction shows the position of the tumor in relation to the vena cava and the right kidney. As evident, the dissection has been carried out on the inferior lateral aspect of the tumor. The dissection is continued superiorly and medially in order to create the dissection plane between the tumor and vena cava taking care not to damage this vessel. Again the augmented reality helps the surgeon during this dissection. Due to the complex pathological anatomy, it is not easy to find a clear plane between the tumor and the vena cava. Dissection is not easy and progress is slow as safety is the first priority. Different augmented reality views can be obtained as demonstrated here in an attempt to further facilitate the dissection.

4. Conversion 03'36''

Due to the difficulty of the operation, a decision was made to convert to open surgery at this point. A transverse right upper incision was made extending from one trocar position to another. Following hemostasis, adequate exposure was obtained in a conventional open surgical way. Here we can see from the open view the dissection that has already been performed laparoscopically. The operation was successfully continued by the open approach.