Laparoscopic right adrenalectomy

This video demonstrates a right adrenalectomy in a patient with a 1.5 cm Conn's tumor. The surgeon mobilizes the superior aspect of the gland and exposes the inferior vena cava. After clipping and dividing the adrenal vein the middle, superior and inferior adrenal arteries are identified, clipped, and divided. The gland is resected completely and removed using a specimen bag. This video provides a good introduction to steps in performing a right adrenalectomy.

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Laparoscopic right adrenalectomy

Authors

Abstract

This video demonstrates a right adrenalectomy in a patient with a 1.5 cm Conn's tumor. The surgeon mobilizes the superior aspect of the gland and exposes the inferior vena cava. After clipping and dividing the adrenal vein the middle, superior and inferior adrenal arteries are identified, clipped, and divided. The gland is resected completely and removed using a specimen bag.
This video provides a good introduction to steps in performing a right adrenalectomy.

Classification

routine cases

Keywords

operation,laparoscopy, right adrenalectomy, Conn's tumor

Media type

Surgical video

Duration

32'00''

Publication

2005-09

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E-publication

WeBSurg.com, Sept 2005;5(09).
URL: http://www.websurg.com/doi-vd01en1054e.htm

Laparoscopic right adrenalectomy

1. Case presentation and trocars 00'15''

Today we are going to perform a right adrenalectomy for Conn’s disease, a tumour of 1.5cm on the right adrenal gland. So here we have the external view of the patient in a total lateral left decubitus with four port sites. The first one here is on the anterior axillary line, just under the costal margin. The other one is 5cm behind the first one, used for the retractor with peanuts that you see here on the grasper. The other one is 5cm just in front of the first one and that is for the scissors, hook, ultrashears. The last one is very anterior used just for retraction of the liver.

2. Exposure and mobilisation 01'27''

We open a trocar because we have some smoke. We follow this direction to go on to the triangular ligament. The first step is very important and consists in opening this ligament because we need a very good mobilisation of the liver. We can use the scissors or the hook; you can see that the retractor of the 1st assistant follows the hook so that we have good traction throughout the dissection. Very important to go on the right side, even if we know that the gland is on the internal part of the monitor. This patient is a little fat but it’s a very small tumour, so the problem won’t be to find the tumour but to have good landmarks. First of all, we will see the vena cava, so we need to have very good hemostasis. We continue the dissection very gently with a good mobilisation. We need to have a good posterior plane because we need to take off all the fat around the adrenal gland. We have to extend dissection a little because we want to see the vena cava. We have no dissection of the duodenum, no dissection of the right colon, we just have the dissection of the hepatoparietal ligament. You can see here that we know it is a normal adrenal gland, but we don’t search the gland, we search the vena cava. We see the anterior and lateral part of the vena cava, the landmark we need to have because the tumour is a very little one. We need to have total ablation of the fat to see the gland properly. We don’t have very good exposure of the vena cava so I change my traction, go to the left part of the vena cava. We need a little more mobilisation of the liver. We need to be cautious because now we are going to see two veins, one is the major adrenal vein and in 4% of cases, an accessory adrenal vein joining the right sub-hepatic vein. You see how important it is to have good exposure using the retractor. Progressively we can have a very good mobilisation. We have the same peanuts since the beginning of the operation; it is a bloodless operation. The dissection of the lower part will usually be the renal vein but as it is a very small tumour we might not have to go very low. We don’t see the adrenal vein and that is the first landmark we want to see. We begin with the lower part of the adrenal gland. Here we have a first vascular element, looks like the medial artery and we always want to begin by the vein unless we don’t recognise it. We don’t use the dissector because it is too big for this very small vein. Now we just have to cut the major vein; you see that immediately it opens like a book and it will be easy to find the posterior part. The next landmark will be the medial adrenal gland. Don’t forget there may be an accessory vein here. This is a good plane with the adrenal gland here, the vena cava here, the hemostasis of the major adrenal vein and the medial artery just coming from the aorta. We put two clips on the medial artery, a very small one we can cut. Then we will need to do a lavage to have a larger posterior plane.

3. Inferior dissection 13'55''

So we have a good plane here: it’s a total adrenalectomy, so we have a good margin from the internal part of the gland. Now we just have to look for the superior pedicle and Toldt’s fascia. Now we have the hemostasis of the superior pedicle. I just want to show the operative field. First we have the hemostasis of the major adrenal gland, after that of the medial artery, now I think of the superior artery and perhaps another here but I don’t think so. The last dissection will be that of the inferior pedicle. This pedicle is not the superior one, but the one of the medial artery. We now normally have no more vascularisation: all the pedicles have been controlled. Now we are in a good plane for a total adrenalectomy, we just want to have a look in the internal part of the dissection. Now we will perform the inferior dissection. It is usually good to see the renal vein, which we don’t see now; the problem will be to find the plane to find the limit between the kidney and the adrenal vein but it’s not so easy. So perhaps we can try to open here and find that good plane.

4. End of the procedure 19'40''

So look again, vena cava, right colon and duodenum here, the liver. So the end of the operation is to find the good plane between the adrenal gland and the kidney. Now we are going to use the ultrasonic device to find the good plane between the inferior part of the gland and the kidney. So it looks like that, here is the fat; here is the kidney and the inferior part of the gland. The only problem is to be sure 100% not to be in the gland. The problem is to see the limit with the kidney. We see the end of the upper part of the dissection. The gland is always very fragile so we must be careful. The only problem is the exposure of the last part of the gland. It’s finished, perhaps one or two little adhesions right here. Just to see the operative field, with a good posterior plane, with a good mobilisation of the liver, a correct dissection of the vena cava. We put the gland in the bag with very little manipulation of the gland. So you can see the gland and the fat around it very well and the operation is finished.