Left pheochromocytoma: laparoscopic vascular approach

Since it was first performed in 1992, laparoscopy has clearly become the procedure of choice for the removal of most functioning and non-functioning adrenal tumors. Compared with those who underwent a standard open approach, patients undergoing a laparoscopic adrenalectomy have demonstrated decreased perioperative morbidity, shorter hospital stay, and faster functional recovery. This video demonstrates how to perform a laparoscopic adrenalectomy showing the surgical landmarks for a correct vascular approach in a stepwise fashion.

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Left pheochromocytoma: laparoscopic vascular approach

Authors

D Mutter, J Marescaux

Abstract

Since it was first performed in 1992, laparoscopy has clearly become the procedure of choice for the removal of most functioning and non-functioning adrenal tumors. Compared with those who underwent a standard open approach, patients undergoing a laparoscopic adrenalectomy have demonstrated decreased perioperative morbidity, shorter hospital stay, and faster functional recovery. This video demonstrates how to perform a laparoscopic adrenalectomy showing the surgical landmarks for a correct vascular approach in a stepwise fashion.

Classification

routine cases

Keywords

Laparoscopic left adrenalectomy, pheochromocytoma, vascular approach

Media type

Surgical video

Duration

11'43''

Publication

2009-03

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Subtitles

E-publication

WeBSurg.com, Mar 2009;9(03).
URL: http://www.websurg.com/doi-vd01en2581.htm

Left pheochromocytoma: laparoscopic vascular approach

1. Introduction 00'09''

The patient is positioned as usual in a right lateral decubitus. To perform the adrenalectomy, we usually use 4 trocars: one operating trocar, two trocars used for retraction, and one that is used to place the laparoscope.

2. Dissection begins 00'26''

The dissection begins at the spleen’s lower pole. The splenic flexure is identified; its adhesions will be gradually freed when encountered. The dissection is performed with the spleen’s mobilization, by preserving around 1cm of the peritoneal reflection. The dissection is performed step by step and aims at the complete mobilization of the spleen and of the pancreatic tail in one single “bloc”, in order to allow them to fall to the right side of the abdomen. The dissection is best performed with a monopolar hook, scissors with monopolar coagulation, or with any other dissection system. The dissection plane corresponds to the Gerota’s fascia. By keeping in contact to it, the dissection of the adipose adhesions and of the connective tissues will allow for a single bloc dissection of the spleen and pancreas: they will then move to the right side of the abdomen thanks to their own weight.

3. Superior dissection 01'20''

The dissection is continued up to the spleen’s superior pole, until we have identified the diaphragm’s left crus and the gastric fundus.

4. Splenic vein identification 01'29''

The first landmark encountered is the splenic vein. This vein allows us to verify that the dissection is well and truly brought to the pancreas’ posterior aspect. The pancreas’ posterior adhesions are gradually freed and the dissection is continued from caudad to cephalad until we have achieved a complete mobilization of the splenopancreatic block. The hemostasis should be perfect so that it is possible to differentiate between the colors of the varying anatomical structures. The hook allows for an almost ideal step by step dissection. The dissection follows the splenic vein for around 5 to 6cm.

5. Splenic artery identification 02'35''

We then quickly identify the splenic artery, which should be mobilized along with the splenopancreatic block. The dissection plane between the pancreas’ posterior aspect and the adrenal gland is avascular. The tissues are exposed thanks to small peanut swabs that have been placed on forceps. The dissection is pursued caudally at the level of the renal hilum. The next anatomical structure that needs to be encountered is the renal vein. Indeed, the renal vein is a major anatomical element that must be identified in order to avoid any confusion with the main adrenal vein.

6. Pancreas identification 03'18''

The pancreas is perfectly identified and is gradually brought out of the dissection plane. Following the opening of the Gerota’s fascia, the renal vein can be identified thanks to its size and axis across the operative field: it goes straight through it from right to left. The adrenal vein has an oblique trajectory, cephalad and external.

7. Main adrenal vein identification 03'50''

Here, a small vascular pedicle will be controlled using bipolar coagulation in order to isolate the main adrenal vein at its origin, when still in contact to the renal vein.

8. Main adrenal vein clipping and division 04'03''

The main adrenal vein can then be controlled by applying a clip, and so as to be safer, a second clip is applied on the side of the renal vein. Before this control, the gland is never mobilized or retracted. The main adrenal vein is immediately divided, thus allowing to retract the adrenal gland slightly cephalad. A few remaining adhesions on the gland’s cranial and external part are freed using monopolar coagulation.

9. Middle adrenal artery identification 04'40''

We can then move to the lower part of the dissection field in order to identify the middle adrenal artery: it runs in a straight line between the aorta and the adrenal gland. Its usual anatomical landmark is the origin of the accessory adrenal vein. In this case, due to the size of the tumor, the accessory adrenal vein is slightly pushed back and the middle adrenal artery is identified before dividing the middle adrenal vein.

10. Middle adrenal artery clipping and division 05'11''

This medial artery is controlled by applying clips, allowing to lift and push the adrenal gland externally with a small atraumatic peanut swab.

11. Accessory adrenal vein identification and division 05'45''

The accessory adrenal vein’s axis that drains into a diaphragmatic vein is then identified. It is isolated in order to be controlled individually by clips. This accessory adrenal vein can be found in every left adrenalectomies. Here again, the hook allows to identify and isolate this vein, before controlling it with clips.

12. Superior adrenal artery identification 06'40''

Once controlled and divided, the freeing allows to free the adrenal gland’s superior portion, at the level of its medial aspect, and to identify at that moment the superior adrenal artery. The latest originates from an inferior diaphragmatic artery and flows straight into the adrenal gland.

13. Superior adrenal artery dissection and division 07'02''

Here as well, it is isolated and dissected with the hook, then controlled by applying clips before being divided. The superior adrenal artery’s division finishes the adrenal gland’s medial dissection along with the adrenal bed’s dissection.

14. Inferior gland dissection 07'20''

The dissection will then be continued on the gland’s inferior and outer aspects. The kidney is the anatomical landmark. The dissection is carried out while in contact to the kidney to search for the inferior adrenal pedicle that has its origin in the renal pedicle. Extra care should be taken at this moment to avoid dividing a superior polar renal artery, as this could complicate the procedure through renovascular hypertension. In this case, the inferior pedicle is identified. Should there be a small associated hemorrhage, bipolar coagulation allows to control it easily. The gland’s entire external aspect will be freed; a small posterior diaphragmatic vein is also systematically present and is controlled using coagulation.

15. Inferior adrenal artery dissection and division 08'46''

The inferior pedicle can then be entirely dissected while keeping the renal vein as a landmark. Following a perfect isolation using coagulation, the inferior pedicle is controlled by applying clips and divided. After having controlled this third arterial pedicle, the totality of the adrenal gland’s vascular supply is controlled. The gland now needs to be freed of its posterior attachments, thus joining with the right and inferior lateral dissection planes and completing the gland’s freeing. The gland will then usually be placed in an extraction bag. The specimen will be extracted through the optical trocar incision, previously enlarged in order to remove the specimen without undue strain or splitting the extraction bag. We do not usually drain the adrenal bed. In this way, we have performed a typical removal of a 4cm adrenal tumor along with its peri-adrenal cellular space. It is of course important to check that there has been no capsular effraction as this could lead to carcinosis in cases of adrenal tumor.