contents
32.1 Position of Patient . . . 313 32.2 Position of the Trocars . . . 314 32.3 Step I . . . 314
32.4 Recognition of the Adrenal Gland . . . 315 32.5 Mobilization of the Adrenal Tumor . . . 316 32.6 Division of the Adrenal Vessels . . . 317 32.7 Exposure and Ligation
of the Right Adrenal Vein . . . 318 32.8 Removal of the Tumor . . . 319
32.1 Position of Patient
The correct position for right laparoscopic adrenalec- tomy is supine with slight elevation (20° to 30°) of the
right side by positioning of appropriate sheets or pil- lows. Slight overextension of the operating table may also be useful to arc the torso further and provide more working space. The monitor is positioned in the familiar position for laparoscopic cholecystectomy for the surgeon and the operating team is similarly posi- tioned.
The only additional precautions are: (a) placement of a urinary catheter since the operation may last longer than expected and (b) the availability of a tray with all the necessary instruments (including a Satin- sky curved clamp) for an immediate open approach should a major complication occurs during surgery, especially with an inferior vena cava injury.
Dimitrios A. Linos
Fig. 32-01
Television monitor
Assistant
Surgeon Assistant
Trocar with insuflation, scope, and camera in umbilicus Trocar sites
Pillow tilts torso 20°
Occasional site for camera Fig. 1
32.2 Position of the Trocars
The initial camera trocar is placed in the umbilicus, as in laparoscopic cholecystectomy, for easier access and delivery of the adrenal tumor. We always use the open Hassan technique, which is faster and safer than the Veress needle technique. Occasionally when we deal with a very obese patient we can place the initial camera trocar closer to the subcostal area in the mid- dle and below the remaining working trocars and avoid the umbilical site. For large adrenal tumors it is more helpful to use an additional trocar for the cam- era at a later stage of the procedure and still start with the umbilical incision, which can be extended at the end of the procedure to allow a larger tumor to be extracted.
There are four additional trocars that are placed in a straight line, 1–2 cm below the subcostal margin starting medially from the subxiphoid, a 10–12 mm
trocar that will accommodate the liver retractor and finish as far lateral as possible with a 5-mm trocar for the first assistant’s grasper. Between these trocars, two additional 10-mm trocars are placed to accommodate the operating surgeon’s equipment and the second
“helping instrument” of the first assistant, which is usually the suction-irrigation tip.
32.3 Step I
The first step is to retract the liver with the gallbladder upwards. The retroperitoneum is incised in order to further retract the liver and reach as high as possible.
The retractor (preferably cloth covered to avoid liver injury) will be held upwards during the whole proce- dure by the second assistant.
Two landmarks are identified: the kidney laterally and the inferior vena cava (IVC) medially.
Fig. 31-02
Right renal vein Duodenum
Liver
Transverse colon Gallbladder
Bile duct Inferior vena cava Retroperitoneal
adrenal gland and tumor
Superior pole of right kidney Line for division of peritoneum
Fig. 2
32.4 Recognition of the Adrenal Gland
Once the posterior liver edge is pushed upwards and the retroperitoneum incised, the surgeon should recognize the yellow color of the normal adrenal tissue and the adrenal tumor. Again the upper pole of the right kidney must be seen and felt and the
IVC clearly seen. The right adrenal vein cannot be seen at this point; its recognition and division should be left for later on. In contrast to left laparo- scopic adrenalectomy, where the adrenal vein can be seen and divided at the earliest stages, the right adre- nal vein lies too high, and it is not wise to go for it first.
Fig. 31-03
Branches of accessory hepatic veins
Adrenal vein Small veins
intermixed with small arteriols posterior to the inferior vena cava
Right renal vein
Inferior vena cava
Adrenal gland and tumor Superior pole
of right kidney
Tiny veins and arteriols from kidney
Fig. 3
32.5 Mobilization of the Adrenal Tumor
The plan to mobilize the right adrenal tumor has two steps. The first step is the “easy” one; it starts from the inferior edge of the adrenal, continues with the lateral one (detaching the adrenal from the upper pole of the kidney) moving upward and along the liver edge. Dur-
ing these efforts, posterior mobilization is also done since there are no vessels between the diaphragm and the adrenal gland. The second step is the more diffi- cult one and includes mobilization and detachment of the right adrenal gland from the inferior vena cava.
This steps ends with the division of the right adrenal vein.
Fig. 31-04 Right renal vein Duodenum Transverse colon Right renal vein
Adrenal gland and tumor eins and arteriols
kidney
Inferior vena cava
Adrenal gland and tumor
Superior pole of right kidney Line of dissection arround the adrenal gland
Fig. 4
32.6 Division of the Adrenal Vessels
The adrenal arteries and veins (with the exception of the main right adrenal vein) are very small and easily dealt with the use of cautery. There is usually no need to use endoclips. The newer forms of energy such as Ultracision (Ethicon Endosurgery Inc.) and Ligasure (Valley Laboratory) are no better than the cheaper cautery attached to the common dissector.One should be patient and careful to skeletonize every small ves- sel and then cauterize it in order to avoid unnecessary bleeding.
The first assistant has the main role of exposing these vessels by pushing apart the tissues in between the vessels. In this figure the assistant applies trac- tion-countertraction between the upper pole of the kidney and the adrenal using a grasper instrument and the tip of the suction-irrigation instrument. The suction-irrigation instrument is a very useful instru- ment because it keeps the space we work in open and clean from smoke and blood at all times.
Fig. 32-05 Suction irrigation
Division of vascularized attachements between kidney and adrenal gland
Adrenal tumor
Superior pole of right kidney Fig. 5
32.7 Exposure and Ligation of the Right Adrenal Vein
The fear of the surgeon during right adrenalectomy re- mains unsuccessful ligation of the right adrenal vein.
The laparoscopic approach allows a better view thus a better exposure and safer ligation of this short and wide branch of the inferior vein cava. The usual laparoscopic dissecting instrument should clearly ex-
pose the adrenal vein as it enters and usually divides in the upper pole of the adrenal. The space is limited but adequate to place at least two clips on the side of the in- ferior vena cava and one on the adrenal side. The small scissor dividing the adrenal vein gives the already mo- bilized adrenal its freedom (and breath to the operat- ing surgeon). One should be careful that occasionally there might be more than one adrenal vein originating from the IVC or even from the hepatic veins.
Fig. 31-06
Adrenal vein
Adrenal tumor Superior pole
of right kidney Fig. 6
32.8 Removal of the Tumor
After the right adrenal vein is safely divided we can then rotate the adrenal tumor all ways in order to cau- terize its last attachments to the surrounding tissues.
Soon the whole adrenal gland with its tumor is hang- ing free at the end of our grasper. The tumor is grasped by the right adrenal vein remnant trying to avoid rup-
ture of the adrenal capsule.We want to inspect the bor- ders of the adrenal gland and remove any yellow pieces left behind. The Endobag can easily accommodate ad- renal tumors as large as 15 cm in diameter. The En- dobag is removed from the umbilical site that occa- sionally has to be extended.After irrigation to confirm that no bleeders are present a drain is left that usually comes out the next day.
Fig. 32-07 Endobag
Adrenal tumor Fig. 7
