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Laparoscopic treatment of an incidental left adrenal mass

Authors

Abstract

This video presents the case of an adrenalectomy in a patient with a non-functional adrenal tumor. A detailed description of the altered anatomy and of the dissection is given.

Classification

complex cases

Keywords

laparoscopy, treatment, incidental left adrenal mass, left adrenalectomy

Media type

Duration

13'00''

Publication

2008-09

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Audio

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E-publication

WeBSurg.com, Sept 2008;8(09).
URL: http://www.websurg.com/doi-vd01en2382.htm

Laparoscopic treatment of an incidental left adrenal mass

1. Cinical case presentation 00'21''

We report a typical case of a patient presenting with an adrenal tumor of 6 by 3cm. This is a non-functional tumor that has to be resected.

2. Spleen mobilization and landmark identification 00'39''

The patient is typically installed in a lateral position. For the resection of this left adrenal mass, the dissection always starts with the mobilization of the spleen. In this patient with a previous surgical history, we can see that the spleen presents several adhesions to the parietal wall. All these adhesions are progressively freed in order to allow the spleen to fall in the right part of the abdomen. This is a key step of the left adrenal gland approach. The gland is typically located behind the spleen very high in the left upper quadrant of the abdomen and this mobilization of the spleen has to be conducted from the lower to the upper part of the spleen. Parietal attachments are progressively dissected either with scissors or with a hook. Serous adhesions between the parietal wall, the diaphragm and the spleen have to be also freed in order to allow the spleen to fall down in the right part of the abdomen without any tear of the capsule, which can lead to parietal wall bleeding or to splenic bleeding. All these adhesions are coagulated. The hook is an essential instrument to coagulate these adhesions. Nevertheless, in cases of very close adhesions as in this case between the diaphragm and the spleen, injuries to the vessels of the diaphragm can occur. Such small injuries can be controlled by compression and by bipolar cautery. Bipolar cautery ideally allows for control of veins and small arteries of 2 to 5mm in diameter. The freeing of the upper part of the spleen is continued until it is completely free and until the mobilization can be pursued. We move back to the lienorenal ligament and we go ahead by the opening of the posterior attachments of the spleen. This is really a key point of the dissection and it is probably the longest part of the surgical procedure. This dissection has to be performed without any bleeding in order to allow nice recognition of all the anatomical landmarks. The spleen and the tail of the pancreas have to be mobilized in one block and the dissection has to be conducted behind the tail of the pancreas. The tail of the pancreas remains attached to the spleen. The correct dissection plane is an avascular plane between the Gerota’s fascia of the liver and the tail of the pancreas. As we see here, mobilization of the spleen is performed without any grasping of the spleen and the spleen falls along in the right part of the abdomen. The dissection up to this step is performed only with 3 trocars; one trocar used for the optic and 2 trocars used for instrumentation. The trocar in the surgeon’s left hand is used to apply tension on the tissue and the trocar in the right hand is used for scissors, coagulating hook or other dissection devices. The anatomical landmarks are very clearly identified during the mobilization of the spleen and the tail of the pancreas. Ideally in a bloodless dissection, mobilization of the anatomical elements allows to identify all the major landmarks. These landmarks are the tail of the pancreas, the adrenal gland can be identified but the major landmarks are the splenic vein and the splenic arteries. These vessels are dissected and followed over a length of 5 to 7cm. they will allow to identify the renal pedicle. The renal vein is the 2nd major landmark, which will allow to progressively identify the main adrenal vein. Some small oozing is controlled thanks to the bipolar cautery and a 4th port is added afterwards in order to allow an assistant to take a grasper to place tension on tissues. This is used to facilitate dissection with the hook. Dissection is continued downwards until the identification of the renal vein. The tissues surrounding the renal vein are progressively dissected with a hook and monopolar coagulation until identification of the main and accessory adrenal veins. These veins are identified in all cases. In this patient, the dissection of the renal vein allows to identify an accessory adrenal vein. This has exactly the same direction than the main adrenal vein. It has to be very precisely identified and controlled in order to avoid a tear of the renal vein after mobilization of the gland. Here we see the main adrenal vein and just near this one, a little accessory adrenal vein directly implanted in the renal vein.

3. Vessel ligation (clipping) and division 07'56''

These 2 vessels are controlled with a clip application in order to achieve a safe control of these veins. The position of the clip is controlled and the vein can be cut in order to mobilize the inferior edge of the gland upwards. After this primary vascular control of the veins of the gland, the dissection will go ahead on the right side of the gland in order to progressively identify the artery. To identify the artery, the dissection is conducted on the left side of the aorta between the aorta and the adrenal gland just close to the diaphragmatic muscle. This represents the posterior dissection of the gland on its right side. Bipolar cautery is very useful to control some little oozing in the operative field. The Ligasure device is very frequently used for this dissection. The first artery to be identified is the medial artery. It originates directly from the aorta. It has a very short length of about 2 to 3cm. It is very carefully cut and controlled by bipolar cautery thanks to the Ligasure device. Dissection is then continued upwards up to the diaphragm. Thanks to this dissection, the right part of the gland is completely free with its surrounding tissue.

4. Adrenal gland external (lateral) dissection 10'17''

The next step is to go ahead to mobilize the external part of the gland. The plane between the adrenal gland and the kidney is identified and the Ligasure device is a very good instrument that allows control of any bleeding of the fat surrounding the kidney. Bipolar cautery is progressively applied and the upper pole of the kidney is identified. The whole fat surrounding the gland is removed with the gland as its pathological status is not known at this stage. This dissections aims to avoid any tear to the capsule of the gland and the gland is never manipulated. The gland is just mobilized thanks to a little peanut placed on the grasper.

5. Adrenal gland upper dissection 11'11''

On the upper pole of the gland, the superior artery originating from the lower diaphragmatic artery is identified and also controlled by application of the Ligasure coagulation device. This bipolar coagulation is very safe for this type of artery.

6. Adrenal gland lower dissection 11'32''

One remaining artery has to be identified; it is the inferior artery originating directly from the renal artery. This is identified at the inferior edge of the gland. This artery is controlled by application of bipolar Ligasure coagulation. At this stage, all the veins and the major arteries are controlled. The dissection of the gland is completed by cutting the posterior fat using once again the bipolar Ligasure device. The gland is completely free.

7. Specimen retrieval 12'38''

As usual at the end of the dissection, the gland will be extracted after introduction in an extraction bag in order to avoid any contamination of the parietal wall. The dissection area is controlled for any oozing or bleeding, which can be controlled by further application of monopolar or bipolar cautery. The surgical procedure is completed by closure of the insertion ports. We never use any drainage anymore in such cases.

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