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Laparoscopic right adrenalectomy for Conn's syndrome

Authors

Abstract

This video demonstrates a standard right adrenalectomy for a Conn's syndrome. The surgeon uses 3D reconstruction from preoperative CT to plan the approach and simulate the position of the trocars. The surgery goes uneventful as planned.

Classification

basic techniques

Keywords

Right adrenalectomy, Conn's syndrome, preplanning, virtual reality, simulation

Media type

Duration

06'00''

Publication

2004-12

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Audio

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E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1650.htm

Laparoscopic right adrenalectomy for Conn's syndrome

1. Case presentation 00'10''

This video will demonstrate laparoscopic right adrenalectomy. The case is that of a 36-year-old female patient who has had arterial hypertension for many years. Blood test reveals the raised aldosterone level with low renin activities suggestive of Conn’s syndrome. The CT-scan showed a 2cm right adrenal tumor.

2. 3D reconstruction 00'29''

3D CT reconstructions was performed using a specialized computer software. This allows us to appreciate the anatomy from different angles as shown. The reconstruction also helps us in preoperative planning and surgical stimulation. This enables us to determine the correct positioning of the laparoscopic instruments before the operation.

3. Trocar placement 01'11''

The patient is placed in a left lateral decubitus position with the legs slightly flexed. This patient is relatively thin and the anatomical landmarks can be clearly identified.

4. Exposure and liver mobilization 01'27''

The liver is mobilized cephalad using the retractor as shown. The dissection is commenced by dividing the hepatorenal ligament to create the right exposure. This is a fundamental step of the procedure.

5. Dissection and identification of inferior vena cava and main adrenal vein 01'47''

Now the dissection is continued medially in order to create the exposure of the anterior surface of the adrenal gland. The vena cava which is visible is an important anatomical landmark. The dissection is continued on the medial aspect of the gland to carefully free it from the vena cava. Here we come to the main adrenal vein.

6. Division of main adrenal vessels 02'20''

This needs to be clipped and divided. The middle adrenal artery lies behind this and can be easily controlled. In between 4 and 10% of cases, an accessory adrenal vein may be found on the right side whereas it is always present on the left, there seems to be no accessory vein in this case. Now the dissection is continued posteriorly to reach the muscular plane on the psoas.

7. Division of superior adrenal artery 02'45''

The superior pedicle originates from a diaphragmatic branch which needs to be controlled using clips. It is important to achieve secure hemostasis of the vascular pedicles as they may be large.

8. Dissection and division of inferior adrenal artery 03'00''

Now we approach the inferior pedicle which originates from the superior polar branch of the renal artery. It is important to take care not to ligate the polar artery itself. A Conn’s tumor is not so vascular, and therefore the vessels should not be so large. It is better not to ligate a large inferior vessel due to the risk of inducing renal ischemia through ligation of the polar artery. This will result in persistent hypertension postoperatively. There is a further pedicle, which needs to be controlled here, and the final inferolateral attachments are divided. Here is the superior polar artery, which has been preserved. Dissection is continued to completely free the adrenal gland. A final thorough inspection is performed where we can clearly see the important anatomical landmarks and the empty adrenal fossa. There seems to be no bleeding. The gland is carefully placed in an endobag for retrieval and this is the end of the operation.

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