Left adrenalectomy for Cushing's syndrome

This video demonstrates the surgical approach to a left adrenalectomy. The patient has a large (Cushing's) tumor of the gland. The surgeon uses a left lateral position. After mobilizing the spleen and the tail of the pancreas, the surgeon identifies the adrenal vein and the accessory adrenal vein, and clips and divides them. He then proceeds to identify, clip, and divide the adrenal artery. The gland is then dissected off the diaphragm and the kidney and removed.

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Left   adrenalectomy   for   Cushing's   syndrome

Authors
J Marescaux, D Fölscher
Abstract
This video demonstrates the surgical approach to a left adrenalectomy. The patient has a large (Cushing's) tumor of the gland. The surgeon uses a left lateral position. After mobilizing the spleen and the tail of the pancreas, the surgeon identifies the adrenal vein and the accessory adrenal vein, and clips and divides them. He then proceeds to identify, clip, and divide the adrenal artery. The gland is then dissected off the diaphragm and the kidney and removed.
Classification
routine cases
Keywords
Left adrenalectomy,operation,cushing's syndrome, laparoscopy
Media type
Duration
28'00''
Publication
2005-05
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-vd01en0064e.htm

Left   adrenalectomy   for   Cushing's   syndrome

1. Case presentation 00'14''
Laparoscopic left adrenalectomy: the patient is a middle-aged female who presents with signs and symptoms suggestive of Cushing’s syndrome. This was confirmed on investigation with magnetic resonance imaging revealing a 5cm tumor in the left adrenal gland. The position of the ports and the patient is as follows: the patient is in a completely lateral position with the table broken to widen the distance between the costal angle and the iliac bone. The mid-axillary line is shown and the optical trocar is not actually put in this mid-axillary line as has previously been suggested but in the anterior axillary line. This is the primary trocar inserted and called A in this instance. The 2 working ports are on both sides of this optical trocar on the left side, port called B through which a grasper or maybe peanuts can be inserted and the trocar C, which will be the right-sided trocar for the surgeon and which will be handling the hook. There is a distance of about 10 to 15cm between the 2 working ports. The 4th port is inserted in the posterior axillary line and this will be used for a retractor. We always utilize a zero degree scope that keeps good view of the whole operative area. On insertion, one immediately sees the spleen and the splenoparietal ligament. This will be divided to allow gravity retraction of the spleen and open up the left adrenal gland. With the scissors or maybe a hook, the ligament can be divided, and as in all laparoscopic surgeries, one will try to find a bloodless plane to continue dissection in it. It’s important to coagulate and cut at the same time thereby decreasing the chance of small bleeders, which will make finding the correct plane quite difficult. The whole of the spleen should be mobilized and remember the patient is in a left lateral position, and dividing this ligament allows the spleen to fall forward. And as one can see, the tissue is very fragile and quite hyperhemic as can be expected in a patient with Cushing’s syndrome. The eventual aim is to deflect the whole splenopancreatic block anteriorly and thereby open up the kidney and the suprarenal gland lying below it. The laparoscope gives an excellent view of this whole area and one can divide bit by bit, thereby finding a nice plane as in this case. One can see the plane opening up there; as for all laparoscopic surgeries, traction and counter-traction is a secret to dissection and in this case, this is actually minimal sharp dissection and a lot of the dissection is done by simply opening up the plane with traction and counter-traction. In that way, one can quickly get to the area that you’re interested in. As you can see, the left grasper is not used to grasp the spleen at all but is simply used as a retractor. This prevents bleeding from the thoracosplenic capsule. Small bleeders are coagulated as one goes along. This prevents the dissecting area from becoming bloodied and planes difficult to find. We now change after opening the peritoneum, we change to a hook, which is very helpful in fine dissection of the fatty tissue around the adrenal gland. The splenoparietal ligament is now almost completely divided and it remains to find the plane between the splenopancreatic block on the one hand, and the adrenal gland on the other. The greater curvature of the stomach is clearly visible superiorly and the gastrophrenic attachments are for the moment left in place. In this case, because it is a very large tumor 5cm, one can see the tumor appearing on this dissection already. Often in this case, one will not see the adrenal gland but we will rather see the pancreas appearing on the left attached to the spleen. The transverse colon in this case is not intruding into the operative field too much. It is always present to a lesser or a greater degree at the splenic flexure and this, the coloparietal ligament is also divided and the colon is allowed to fall down towards the midline together with the spleen and the pancreas. The idea is once again to find a bloodless dissecting plane, which is always present even if one cannot see the tumor or the actual adrenal gland, as in this case, there’s usually a very nice plane just below the pancreas and the spleen as one can see in this case. Using peanuts to retract and not sharp instruments or graspers allows one to do a really careful and atraumatic dissection and it gives excellent retraction. This hook in the same vein allows careful dissection of tissue without much bleeding and allows the planes to be clearly seen. It’s really a beautiful plane opening up before one and it’s simply a matter of traction on the one hand and counter-traction and then dividing only the small fibers but it is clearly a bloodless plane. The pancreas is visible now below the peanut. One can clearly see the tumor and then the inferior pole of the adrenal gland, which is actually quite normal and the border is in this case beautifully shown shining through the remaining connective tissue. The pancreas on the left of the screen is pushed medially and one searches for the splenic vein, which is used as a guide to find the adrenal. The greater curvature of the stomach is still attached to the diaphragm and this can also be liberated to allow this whole block of tissue: the pancreas, the spleen and the stomach still attached to the spleen with the short gastric vessels to fall forward and medially opening up the space. Utilizing a lateral approach and having the patient in a completely lateral position allows one to do this. Shining through in the distance are the diaphragmatic vessels and these are a reasonably constant finding and can be used as a guide to the adrenal gland as well. The inferior diaphragmatic vessels are now becoming clearly visible and the whole stomach, spleen, and pancreas is allowed to fall out of the operative field. This saves one from utilizing fan retractors and so on and gravity is used as a retractor. With sucking on the stomach, we will also decrease the intrusion to the operative field and now continues towards the area of the adrenal. The pancreas is pulled back gently with the peanuts and dissection is continued by traction and counter-traction. A 2nd peanut inserted through the retractor port posteriorly allows one to triangulate a nice plane for dissection. Once again, this is a bloodless plane and provided one gets into the plane between adrenal gland and splenopancreatic block on the other, there are no blood vessels. Using the peanuts, one can easily open up the space without causing damage with graspers or grasping tissues. One has to continue dissection inferiorly to a greater or lesser extent to delineate the gland and delineate the vessels. The tumor is not clearly visible and we will continue dissection to find the vascular supply of this tumor. Normally the accessory adrenal vein flows into the inferior diaphragmatic vein and one can easily find that this pedicle. We routinely are trying to find the splenic vein and use that as a guide to the renal and the main adrenal vein. In this case, it is very easy to find the adrenal vein by simply following the inferior diaphragmatic vein downwards. The vessel is beautifully shown and one can continue dissection right on it and try to find the main adrenal vein, which is starting to appear behind the hook here. Once again, it’s important to use gentle traction with both the peanuts through the posterior port as well as the peanut in the operator’s left hand. This large vein appears to be the main adrenal vein and we will continue to dissect it open and try to get around it. We always use this approach of finding the vessels first and getting the vascular control of specifically the vein. It might not be that important in a patient with Cushing’s syndrome but certainly in someone with a pheochromocytoma, this can be a lifesaving measure. Using the peanut as well allows minimal traction and manipulation of the actual tumor. Clearly seen here, the pancreas is pulled away to one side, the adrenal gland at the other side and one has to open up the space inferior to allow access to the vascular pedicle of the adrenal gland. The accessory adrenal vein will also originate from this inferior phrenic vein and we will search for that later. However, for the moment, attention will focus on the main adrenal vein, which is starting to be dissected out very clearly. This is now being dissected for about 2cm and one can see the anatomy ahead. We’re quite certain that it’s not running to the kidney or anywhere else but that it is indeed the adrenal vein. We continue to dissect this vein and get around it to get proximal control. Using the hook is really helpful in these cases as it allows one to do fine and intricate dissection with minimal chance of bleeding. The hook also allows one to go around tissues as in this case with minimal damage; especially in this patient with Cushing’s syndrome, certainly one needs to be very gentle and atraumatic in retraction and dissection. Once the vein has been isolated, it is an easy matter to clip it and thereby the major part of this operation has actually been completed. Two proximal clips are applied and another one distally. It’s easier to turn the clip around. It allows one to see where you’re putting the clip and leaves a nice distance in between. Before cutting it, we’re ensuring that there’s a good cuff of tissue. One can also put a suture or an Endoloop around this if necessary but in this case it appears that there’s excellent control using the clips alone. There’s the vein, which has been controlled with 2 clips on that side, there’s a small bleeder at the back controlled with bipolar diathermy. One still needs to get control of the inferior phrenic vein, which courses superiorly from this vein. Once again, dissection has the aim of liberating the vein, getting around it, and then applying a clip to it. We can nicely see the vessel running superiorly, the main adrenal vein, and after division and ligating of this vein, one can go looking for the accessory adrenal vein, which probably also drains into this inferior epigastric vein. We continue dissection upward to look for this accessory adrenal vein and the superior pedicle. The plane is right on the diaphragm. One can see the diaphragm at the back and that is once again a bloodless plane that gives an excellent dissection. Eventually at the end of the operation, we aim to have the diaphragm lying clear at the back and all of the adrenal vein taken away from it. Here’s the pedicle clearly seen. We see the diaphragmatic vessels at the back and this is the accessory vein draining into it and the superior pole of the adrenal vein. It is quite a substantial vessel and it will need to be clipped as well. Once again, using this vascular approach to the adrenal allows one to get meticulous control of all blood vessels and thereby turns this into an operation that can be reproduced, an operation that allows one to find landmarks every time and dissect according to that. The diaphragm is clearly visible at the back. Lateral to this now, there are no important vessels. We know that we have got the main blood supply coming in from medially and we have got the accessory vein and the main adrenal vein coming in. And now we need to find the adrenal artery, which is usually coming from the aorta. One can clearly see the vessel and this is once again clipped. The adrenal artery is always to be found at the back of the vein and once that we have located the vein and got control, it is usually an easy matter to go forward and dissect out the artery and control that as well. There’s a small lymph node sitting here. The blood supply around it is clipped and cut. There’s a small artery there and that’s the main arterial supply of the gland controlled. So in overview now, we have the accessory vein, we have the superior artery, we have the medium artery supplying the gland and we’re now going to search for the inferior pole of the gland, which as we previously noted is normal, and find the inferior pole and its blood supply. We always perform a laparoscopic total adrenalectomy and this allows one to do this reproducible method of adrenalectomy and find the pedicles as shown. In this case, the inferior pole of the gland is clearly visible and dissection is continued inferior to it and the gland is slowly dissected away with counter-traction and traction from the fatty tissue and capsule of kidney. Once again, a small beautiful plane is found at the back and the inferior pole is clearly visible. This can be divided. The inferior pedicle of the adrenal gland is divided there. One can then almost, just using blunt dissection, one can pull the adrenal gland away from the connective tissue. We continue now with dissecting out the inferior corner. It looks like it’s another vessel; in the tissue here, there’s another small pedicle. This is cut, dissected away and that frees the inferior corner of the gland. The hook is very good for this fine dissection and allows one to slowly go through all the connective tissue. We’re also using the ultrasonic dissector in this instance. It is probably not totally necessary. The ultrasonics does allow one to take bigger bites and to do a quicker procedure. There’s another small vessel and can also be easily managed with ultrasonics. The whole of the gland is now liberated. One can see this is only held by a small inferior attachment and this can be divided knowing that most of the major vascular supply has been dissected. Here’s the small last little inferior pedicle, and we will use a last clip on this to ensure good hemostasis. After division of this inferior pedicle, the adrenalectomy is completed with using the ultrasonic dissector. The gland has been liberated completely and the procedure is almost finished. Clearly visible is the tumor and the normal adrenal gland inferior to it. We didn’t use any suction. We just used the peanuts for retraction. That’s really the secret to this procedure, giving good and careful dissection using gentle retraction of the peanuts and finding the vascular pedicles first and using a vascular approach. That’s the bed of the left adrenal; at the back is the diaphragm visible and it’s clear that a total adrenalectomy has been performed with minimal bleeding and minimal disruption of the adrenal gland prior to dividing the vessels. The pancreas has been liberated for more than 5cm and one clearly sees at the bottom the vascular pedicle of the adrenal vein. It’s important to get this good exposure by dissecting the pancreas and the spleen medially. The accessory adrenal vein is visible, the artery at the back, and also the superior pole that was dissected out, the superior pedicle coming from the diaphragmatic artery that was divided. The last overview is given looking for bleeders and here the Endocatch bag is inserted. We always use a bag to remove the tumor because they are friable and want to break up and rupture on removal. The Endocatch easily passes through in the 5mm port and it’s not a problem utilizing it in this case. The whole of the tumor is inserted in it and removal after that is quite easy. We do not utilize drainage in these patients for obvious reasons. There’s very little oozing and bleeding from the operative field; the dissection has been in a bloodless plane and all the vascular pedicles are well controlled with clips. The patient will be covered in the postoperative period with corticosteroids, and after removing the specimen, removal of the ports leaves only 4 small holes, excellent in a patient with Cushing’s syndrome.