Laparoscopic resection of a right pheochromocytoma: anatomical variation of the main adrenal vein

Laparoscopic adrenalectomy has now become the new "gold standard" for the surgical treatment of most adrenal lesions. Here we show a film of right adrenalectomy for pheochromocytoma, demonstrating the conventional "no touch technique" where the dissection takes place around the gland without really manipulating it. The film also demonstrates the anatomical landmarks as well as the principles and sequence of vascular control.

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Laparoscopic resection of a right pheochromocytoma: anatomical variation of the main adrenal vein

Authors

D Mutter, J Marescaux

Abstract

Laparoscopic adrenalectomy has now become the new "gold standard" for the surgical treatment of most adrenal lesions.
Here we show a film of right adrenalectomy for pheochromocytoma, demonstrating the conventional "no touch technique" where the dissection takes place around the gland without really manipulating it.
The film also demonstrates the anatomical landmarks as well as the principles and sequence of vascular control.

Classification

basic techniques

Keywords

Laparoscopic resection, right pheochromocytoma, adrenalectomy, main adrenal vein

Media type

Surgical video

Duration

08'30''

Publication

2009-02

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E-publication

WeBSurg.com, Feb 2009;9(02).
URL: http://www.websurg.com/doi-vd01en2537.htm

Laparoscopic resection of a right pheochromocytoma: anatomical variation of the main adrenal vein

1. Clinical case presentation 00'17''

This is the case of a 60-year-old lady presenting with a 4.5cm right adrenal tumor diagnosed since she was suffering from back pain and we got biological confirmation that this tumor was a pheochromocytoma. This is a 4cm tumor pushing on the inferior vena cava.

2. Port positioning 00'51''

We start with one port using an open approach of the anterior clavicular line. Two 10mm ports are placed 5cm on the right and on the left. One 5mm port used for the liver retractor is placed just below the xiphoid process.

3. Liver mobilization 01'10''

I have only started the liver mobilization because I was unable to place this retractor below the liver. Here you can see that there is a hypervascularization typical of a pheochromocytoma. In this type of procedure, the hook really allows to have a very precise cutting of the elements. Here you can see that I grasp the peritoneum below the liver millimetres after millimetres. The objective is to dissect these landmarks and control the main adrenal vein before making any dissection or manipulation of the tumor itself. We go back and go ahead with the freeing of the inferior attachments of the liver in order to identify the vena cava. I will retract the liver as high as possible. Here probably there is the junction between the gland and the tumor. The triangular ligament opening will be the key for the success of the exposure of the gland because it will really allow my assistant to lift the liver without tension. Dissection is going on always following the same landmark. I move a little bit more on the triangular ligament. You can see that the dissection plane is made externally by the diaphragm but most important,

4. Dissection of vena cava 02'36''

what I’m starting to do now is to dissect the internal landmark, which is the vena cava. To dissect it completely, first we go downward. The dissection always goes a little bit lower than necessary. Usually the main landmark for the lowest part of the dissection is the origin of the renal vein. Here it’s probably here as the axis of the vena cava is there. That is the back of the vena cava. That’s the lateral side and that’s the anterior one. Remember the patient’s position. Usually if the operation goes well, there’s no control of the vena cava. The preoperative imaging did not show any thrombus in the vena cava, which is another risk. One of the risks at this level is to have a direct hepatic vein. We have dissected along the vena cava and what we have identified is here, a direct hepatic vein joining the same junction than the adrenal vein. Here we have a small direct hepatic vein. Here we have the inferior border of the adrenal vein, and here the upper border of the adrenal vein.

5. Clipping the main adrenal vein 04'10''

And now I tell the anesthesiologist that we are clipping the main adrenal vein, because after this clipping, there will be a risk of arterial blood pressure drop due to the lack of hormones. Here’s the clip on the side of the adrenal gland, here we know that there is a little risk of bleeding. I will cut this vein progressively always in 2 sections, first half of it to control if it’s perfectly tied, and then I cut it.

6. Dissection of the upper pole and arterial control 04'47''

Here the objective is to complete the dissection of the upper pole, which will lower the gland. After lowering the gland, the next objective will be to progressively dissect the arteries. So the next step of the dissection is to free the arteries coming internally. Here I identify very clearly the origin of the renal vein. The dissection is complete and has permitted identification of all elements. You can see there is probably a little vessel here, which explains the previous bleeding. There are two things. You see that we never grasp the gland. It is one of the rules of this dissection.

7. Dissection of the lower pole 05'46''

I will use the hook again to open the peritoneum. The objective is to perform a complete resection of the entire pathological area. Here we are on the kidney. So the kidney is the inferior landmark of dissection and it’s interesting because we are very safe and at distance of the gland, and this is the best inferior landmark we can imagine. If we move in this direction, we will be able to identify the last potential vascular pedicle. Here you can see a little vein very clearly coming from the gland and it’s probably the vein at the origin of the remaining diffusion of the patient’s hormones. I will take this vein with the Ligasure device. This little vein is controlled here.

8. Posterior dissection 06'43''

This fat will be taken out with the Ligasure because sometimes in this posterior fat, there is also the possibility to have one or two very little accessory veins. So the Ligasure offers a very good bipolar cautery. So you’ll have the final view. There’s a little liver fracture that will be controlled afterwards. Here you have the final view of the gland. You can see the upper pole of the renal artery here. That’s why you have to avoid vascular hypertension. Renal vein, pedicular artery and the final dissection of the pheochromocytoma will be done with posterior application.

9. Final view and end of dissection 07'37''

Here you can see the final view: the vena cava is here, the whole area of the adrenal gland is taken out. And I will finally check what’s coming from the liver and bleeding but the final view is here.