33 Left Anterior Laparoscopic Adrenalectomy Dimitrios A. Linos

contents

33.1 Position of the Patient . . . 321 33.2 Placement of Trocars . . . 321

33.3 Step I: Mobilization of the Left Colonic Flexure/Exposure of the Upper Pole of the Left Kidney and Pancreas . . . 322 33.4 Step II: Mobilization of the Inferior Border

of the Pancreas Along with the Lower Pole of the Spleen; Exposure of the Left Adrenal Tumor . . . 323

33.5 Step III: Mobilization of the Adrenal Tumor . . . 324

33.6 Step IV: Removal of the Tumor/Drainage . . . 324

33.1 Position of the Patient

The patient is positioned in the lateral right decubitus position. A pillow is placed under the flank and the table is angled to increase the space between the costal margin and iliac crest.The surgeon stands on the right of the table with the monitor across behind the head of the patient. The assistant stands opposite to the pa- tient.

33.2 Placement of Trocars

The first trocar for the camera is placed in the umbili- cus using the open technique. In the case of an obese patient a separate camera trocar is placed below and underneath the trocars for the instruments.These four

additional trocars are placed along a subcortal line.

The first one is placed in the midline to accommodate the endoretractor. The remaining three are placed at 5-cm intervals with the last outer one as laterally as possible. All trocars are 10–12 mm diameter in order to accommodate all the necessary instruments expect the very lateral one, which can be a 5-mm one.

33 Left Anterior Laparoscopic Adrenalectomy

Dimitrios A. Linos

Umbilicus

Fig. 1

33.3 Step I: Mobilization of the Left Colonic Flexure/Exposure

of the Upper Pole of the Left Kidney and Pancreas

The left colonic flexure and descending colon are mobilized inferiorly and medially in order to ex- pose the underlying upper pole of the left kid- ney. The tip of the surgeon’s working instrument

could “sense” the hard surface of the kidney be- hind the Gerota’s fascia and the overlying retroperi- toneal fat.

Further division of the gastrocolic ligament and mobilization of the transverse colon downward allows exposure of the pancreas. The use of new forms of en- ergy such as Ligasure (Valley Laboratory) and Ultraci- sion (Ethicon Endosurgery,Inc.) may expedite this and subsequent steps.

Dimitrios A. Linos 322

Fig. 32-02

Stomach

Adrenal

Pancreas

Kidney Spleen

Colon Fig. 2

33.4 Step II: Mobilization of the Inferior Border of the Pancreas Along with the Lower Pole of the Spleen;

Exposure of the Left Adrenal Tumor The retroperitoneum along the inferior border of the pancreas is opened with diathermy. The attachment of

the lower pole of the spleen to the upper pole of the kidneys is divided. The main purpose is the upward mobilization of the inferior surface of the pancreas along with the spleen. The characteristic yellow color of the adrenal tumor will now start appearing behind Gerota’s fascia. The laparoscopic retractor is now in- serted to keep the pancreas away from the adrenal.

33 Left Anterior Laparoscopic Adrenalectomy 323

Fig 33-03

Stomach

Spleen Pancreas

Colon

Left kidney Adrenal gland tumor

Fig. 3

33.6 Step IV: Removal of the Tumor/

Drainage

The tumor is grasped by the left adrenal vein remnant or surrounding non-adrenal tissue, trying to avoid

rupture of its capsule. It is positioned in the Endobag, which is retracted through the initial umbilical port.

The umbilicus has the advantage that we can easily ex- tend the incision to accommodate large tumors with minimal esthetic cost. A drain is positioned for 24 h.

Dimitrios A. Linos 324

Fig. 33-04

Stomach

Adrenal tumor Pancreas

Kidney Spleen

Colon Renal vein

Left adrenal vein Renal artery

Fig. 4

33.5 Step III: Mobilization of the Adrenal Tumor

1. We start the mobilization of the tumor from its in- ner border in the essentially avascular space be- tween the pancreas (that is retracted and protect- ed by the endoretractor) and the adrenal. We con- tinue deep along this plan mobilizing most of the posterior surface of the tumor.

2. We then move along the superior surface that again is essentially without major vessels requir- ing separate clip ligation.

3. We continue mobilizing the external border of the tumor from the inner surface of the superior pole of the kidney. There are few vessels requiring care- ful hemostasis to keep the vision clear.

4. The most “difficult” part of this mobilization comes on the inferior border of the adrenal tumor especially recognizing and dividing the left adre- nal vein that comes off the left renal vein 2–3 cm from the hilum of the kidney.The pulsating left re- nal artery needs also to be recognized and pro- tected.

Most left adrenal arteries and veins are small and only

the left main adrenal vein (and occasionally another

medial accessory vein coming from the inferior

phrenic) needs clip ligation. Monopolar diathermy

and/or other sources of energy (Ultracision, Ligasure)

provide safe and fast hemostasis.