Laparoscopic left adrenalectomy for Conn's disease: transabdominal approach

This video demonstrates a laparoscopic left adrenalectomy in a patient with a small Conn's tumor. There is an anatomic anomaly of position of inferior vena cava identified by preoperative CT-scan. The surgeon demonstrates the identification and division of adrenal vein and accessory adrenal vein, as well as the superior middle and inferior adrenal arteries.

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Laparoscopic   left   adrenalectomy   for   Conn's   disease:   transabdominal   approach

Authors
D Mutter, J Marescaux
Abstract
This video demonstrates a laparoscopic left adrenalectomy in a patient with a small Conn's tumor. There is an anatomic anomaly of position of inferior vena cava identified by preoperative CT-scan. The surgeon demonstrates the identification and division of adrenal vein and accessory adrenal vein, as well as the superior middle and inferior adrenal arteries.
Classification
routine cases
Keywords
Conn,adrenal glands,laparoscopy,left adrenalectomy
Media type
Duration
30'00''
Publication
2003-02
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Feb 2003;3(02).
URL: http://www.websurg.com/doi-vd01en1409e.htm

Laparoscopic   left   adrenalectomy   for   Conn's   disease:   transabdominal   approach

1. Case presentation 00'33''
Here is the position of the ports that we usually use in our department, today we are putting four ports along the costal margin as you see here. The first port that we insert is a 12mm port that we insert by an open approach, it is the optical port. 5cm on the left and right side on the axillary line, we put the 1st port that will be used for the scissors, camera on the anterior axillary line, and another one 5cm away for the grasper or peanuts to retract the organs. A little later I will insert a posterior port to retract the fat and to retract the elements. Here you see the liver, the patient is in a complete lateral position, here we have the stomach, here the spleen, some adhesions of the Toldt’s fascia coming in front that will be cut in order to free the space to free the spleen completely; here below the colon you see the anatomical abnormality we saw on the CT-scan with the vena cava located on the left side of this patient and the aorta placed below on the right side of the vena cava, almost free in the abdomen with some nodes here. None of the faculty have much experience with the left-sided vena cava, where do you anticipate the left adrenal vein is going to go? It is the same for us, we didn’t have much experience with this anatomical abnormality; when we look on the CT-scan, we saw that the vena cava goes on the right side at the level of the renal vein, so I suppose I will have no particular specificity concerning the dissection and after the mobilisation of the spleen, I will try to identify this abnormality on the posterior aspect. I will start the procedure by mobilising this small adhesion to have access to the posterior aspect of the spleen. Here you see that I have lowered this small adhesion along the colon, here I have a mass that I suppose to be the kidney, it is not the objective of my dissection, now the objective is to mobilise the spleen downwards. I adjust the angle of the camera and I go posteriorly to mobilise the parietal attachment of the spleen. I try to keep 1cm of peritoneal sheath along the spleen in order to grasp it. Here when I don’t see any more the attachment of the spleen, I go again in front of my dissection area and again my objective is mobilisation of the spleen. I stay as far as possible, here I use the little peritoneal attachment I kept on the spleen, you see that it allowed me to present this attachment here. Regarding the anatomical abnormality we have seen on the CT-scan, we know that the pancreas goes very low on the kidney and the danger could be to dissect between the spleen and the pancreas. So the first step is the mobilisation of the spleen, the second step will be to identify the position below the spleen behind the pancreas and not between the spleen and the pancreas. I would need help to lower this tissue, so I will insert my 4th port. Do you utilise a 4th port in most of your patients? Yes, because I think it is very useful to retract the organ. Here I am afraid to be too close to the colon, which is attached here, I will lower a little bit more the colon here to avoid any injury of the colon. I think it is really a specificity here to use a 10mm port because we consider that to be a safe approach; through this 10mm port, we can insert either the little peanuts or a vascular clamp or an angulated one to control vascular bleeding if necessary. I start the mobilisation of the spleen again, here is probably the kidney. My next step will be to find the posterior aspect of the pancreas. Here I have the splenic vessel, probably the splenic artery, I have to find the correct plane behind the pancreas. I will open the tissues here. Emphasis on how important it is to find that plane posterior to the pancreas and not anterior. You have seen on the CT-scan that the pancreatic tail is in the kidney hilum, and here you see that I have identified in this place the splenic artery and splenic vein but in front of me, I probably have the tail of the pancreas. That is why my dissection will quit the normal dissection plane of the spleen, but you see that the spleen is no longer in the operative field and now I have to go dissect below the pancreatic tail, and here I have it and its fat. We keep all these elements together and I will continue my dissection posteriorly to these elements in order to really go in the posterior plane and to mobilise posteriorly the tail of the pancreas. I think that the splenic vein is really a landmark that you have to follow, here you see that I have the pancreatic tail going much further on the lateral side than usually. I think this is probably due to the little anatomical abnormality this patient has. My dissection has to mobilise the tail of the pancreas posteriorly, the objective is to find again posteriorly the splenic vein and following it onwards will allow me to find the renal vein. I think that the renal vein is really the major landmark we need to identify. With some experience, you know where you must go; I should go on the left crus, in the avascular place lateral to the gland and identify downwards somewhere the renal vein. I know due to the particular anatomy of the patient that the renal vein will probably be a little bit lower than it is usually. Here I have followed the splenic vessel and downwards I should find somewhere here the renal vein. I open the Gerota’s fascia as it is behind it and here I will try to identify the vein. Here I have the renal vein, there is also a risk of not being able to identify the genitourinary vessel, which is probably also abnormal here. Here I begin to identify very precisely the vessels. This could be the adrenal vein but we are not sure at all. I will continue dissecting all the vascular elements here. I will just open the Gerota’s fascia. Do you think that by retroperitoneal approach, dissection can be made easier considering this kind of abnormality, you will dissect the gland first? I really don’t know because I haven’t had this case before but when I look at the CT-scan again, it would be very easy to go there but I’m not sure whether I would have to cross some vessels, which would be too big. It looks like normal anatomy here if you consider that our vena cava could be the renal vein, you have the renal vein here, the vena cava crossing on this side, the main adrenal vein here and the accessory adrenal vein that we have identified all the time is probably here. I think that in such a patient, it is very important to have a complete exposure of the vascular elements in order to be completely safe. I can very safely put clips on this vein, but I go on dissecting all these little elements in order to avoid pulling on anything. That is really near the vena cava; for safety reasons, I put a second parallel clip, then I first clip close to the accessory adrenal vein, so I will have the possibility to cut the vein safely, and then to go on the accessory adrenal vein. You need to look for that accessory vein carefully. Now I have completed the venous landmarks of my adrenal, and here just below the vein, I have some nodes. Here is the little arterial supply with a node here, that is probably a little branch of the medial artery, which I cut. I can go on the lateral dissection because this will be a free space here from down to up. My assistant changes position, he will mobilise the gland but the objective is to place tension on the tissues. That looks like a very friendly plane going superiorly there. Yes, usually this plane has almost no major vascular elements, the vein is completely coagulated, you have vascular arterial elements that you can identify and the adrenal artery is upwards. Here you identify the lateral aspect of the gland, this means that my right dissection of the gland is completed, the plane is completely avascular here. This is feasible when you avoid any infiltration of the gland with blood coming from the operative field. I have to retract the spleen, that is due to the fact that I did not complete the mobilisation upwards and with some centimetre more cautery, the spleen will fall completely out of the operative field. It is very important to mobilise as high as possible lateral to the spleen. Even if you didn’t mobilise at the beginning of the procedure, you can complete the mobilisation at any step of the operation. You see now the greater curvature of the stomach, that means that you are very high and close to the crus. Here you see very well the right border of the gland, here I am in the retrogastric space, I will go on opening here these attachments, the correct dissection plane is here. Now the spleen should fall away, shouldn’t it? Yes, it should. Here we can identify the upper artery. I have the spleen falling in the operative field because it is completely free. Here you see how fine we identify the diaphragm. Even if you did not identify the gland completely, you are sure when you are in this plane that you have removed the whole gland because you have removed all the adrenal area. Here is the upper pedicle of the gland, which will be controlled and clipped now. It is important to have an assistant who can correct the camera angles, hold it still. Here you see the control of the pedicle, you see the edge of the gland, and you see that the internal dissection of the gland is finished, now I can mobilise it completely upwards. I have very well identified the kidney and the gland here so I can now mobilise it upwards and on this side. The inferior pedicle is missing, this one will be found inferiorly after mobilisation of the external part of the gland. You see how quick you can have local sealing of cells with adrenal, that’s why I absolutely try never to grasp the gland until the end of the procedure. Now that I have the internal and posterior parts, I think I will identify here posteriorly the last vascular pedicle, the inferior one that is coming here. It usually comes directly from the renal artery, here are the adhesions on the nodes and here are the arteries. I will put a clip on the pedicle here. Here to finish, it is possible to have a perfect and complete control of the fat. The instrument in my right hand is the Ligasure device developed by Valleylab Tyco, it is I think the most recent and best invention offered by companies to control the dissection and the fat of patients, you can make a complete cautery and you cut in the middle because there is a knife in the middle of the device, I can do right and left cautery and divide in the middle. It does not prevent injury that is why it is not good to use it before identification of all the vascular landmarks because there is a risk of cutting into the gland. The Ligasure device is exceptional, you can have the hemostasis of A and E, even on the aorta of the pig I remember it was done. Because it is so good it can be dangerous, even though you have this instrument and can do the hemostasis of everything, you still need to have a good exposure and a good individualisation of all the vessels. Now I will modify the exposure of my operative field, you see that I have to dissect here the fat between the kidney and the adrenal. You see that I may have a vessel here so I prefer to control directly what I am doing, I will change my instruments. Here I think it is important to open the Gerota’s fascia, you can safely finish the dissection, I have identified the kidney, here the fat. I will finish with the Ligasure. To remove the adrenal gland from the peritoneal cavity, I always place the adrenal in a bag in order to avoid any cell spillage on the parietal wall, which is very important, we don’t put a drain anymore as I think that is useless because when you have a complete hemostasis like that, the spleen falls down in the operative field so you don’t need to drain anything. I want to show you that even for this type of dissection I have left some tissue and you see that I don’t grasp the gland, I really only grasp all the fat around the tissue, the little retroperitoneal sheath, but never the gland in order to avoid cell spillage. I don’t look for the tumour, I don’t really look for the gland. Here you see the complete operative field and I will show you again the anatomical landmarks. I put 2 peanuts, here is the adrenal area completely free on the muscles, here the adrenal vein that has to be safely identified. Here we have this anatomical abnormality with the vena cava crossing the abdomen here. Here you see our landmark with the spleen that falls out of the operative field, the stomach, the great curvature that we identified upwards and downwards, all the elements are completely dissected and you that the spleen stays out of the operative field. The very important landmark to identify first is the splenic vessel and to go posteriorly to the pancreas. Here I want to stress the need to identify the position of the pancreas. We saw on the CT-scan that the pancreas was placed on the renal vessel and that is why I started the dissection here to mobilise completely the pancreas that is here, you see the tail of the pancreas that is also out of the operative field pulled by the spleen. Here you see the splenic vessels, I used this landmark to go down and here you can identify the splenic vein posteriorly and this indicates the direction in which you have to dissect to look for the renal vein usually; it acts like an arrow. When you follow down here the direction of the splenic vein, you always find the renal vein down there, here in fact it is the vena cava and then you come back until you cross the main adrenal vein. It’s the key point of dissection When you have identified this lower elemen,t then you just have to remove everything between the crus on this side and the kidney on this side. Whatever the size of the gland or the tumour, you are sure to remove all your pathological elements that may be here inside.