Transcript Laparoscopic Adrenalectomy - University of Kentucky | Medical Center

Laparoscopic Adrenalectomy:
A General Overview
The University of Kentucky
Minimally Invasive Surgery
Lab
By Taylor Baldwin
Adrenalectomy: Overview
 Patient History, Work-up, and Diagnosis
 The Laparoscopic Method
 The Operating Room
 Equipment
 The Procedure
 Complications and Post Operative Care
Patient History
 A 54 year old male presents with the following
symptoms:
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An episodic headache
Excessive sweating
Tachycardia
Hypertension
Anxiety
Weight-loss
Elevated blood pressure
Workup
 Initial symptoms fit the classic model of
pheochromocytoma
 A CT scan indicates a small (3cm) mass on the left
adrenal gland.
 Further biochemcial testing reveals elevated
metanephrines (metabolite of catecholamines) in the
urine, indicating an over secretion of catecholamines in
the medulla of the adrenal gland.
 This evidence leads to a strong indication of
pheochromocytoma in the left adrenal gland.
Possible Methods for Treatment
 Surgery (either open or laparoscopically) is the clear
first choice treatment of these patients.
 A combination alpha/beta blocker can be used to treat
patients in an attempt to slow the heart rate. This
treatment is often used with surgery as a preoperative
treatment to prevent intraoperative hypertension.
 Ultimately, the tumor needs to be removed.
Indications for the Laparoscopic Method
 Functional adrenal cortical masses
 Cortisol-secreting adenoma (Cushing’s adenoma)
 Aldosterone-secreting adenoma (Conn’s disease)
 Adrenal cortical hyperplasia (Cushing’s disease)
 Functional adrenal medullary masses
 Pheochromocytomas (tumor of medulla of adrenal gland)
 Nonfunctional adrenal tumors
 Adenoma (“incedentalomas”)
Contraindications for the Laparoscopic Method
 Adrenal Carcinoma
 Adrenal masses greater than 10 cm
 Untreated Coagulopathies
 Surgeon Inexperience
 Surgical history of kidney or liver
 Increase risk of adhesions making transperitoneal approach
impossible
 Make for much riskier dissections
Advantages of the Laparoscopic Method
 Reduced wound morbidity
 Shorter hospital stay
 Easier/quicker return to normal activity
 Reduced postoperative pain
 Due to absence of large surgical wounds
 Magnified view of operative field
 Less blood loss
Open vs Laparoscopic Adrenalectomy
Open
Laparoscopic
Operation Time
4 hours
3 hours
Reoperation
Frequency
4.8%
1.4%
Length of Stay
9.4 Days
4.1 Days
Morbidity Rates (30
day)
17.4%
3.6%
Based on a 2004 study:
http://linkinghub.elsevier.com/retrieve/pii/S1072751508000707
Patient Positioning
 The patient is placed on
the operating table
slightly flexed at the
waist in the right lateral
decubitus position.
 A cushion can be used
under the lumber fossa
on the contralateral side
to open the operative
field and help with
trocar placement.
Team Placement
 The primary surgeon stands facing the abdominal side of
the patient
 The second surgeon will also be standing on the
abdominal side of the patient
 The assisting nurse stands on the opposite side of the
patient, facing the surgeon
 The anesthesiologist/anesthesia tech typically stands at
the head of the operating table on the side of the
assistant
Team Placement (Continued)
Primary
Surgeon
Anesthesiologist
/ Anesthesia
tech
Assisting
Nurse
Assisting
Surgeon
Equipment Placement
 The operating room is centered around the operating
table
 The anesthetic equipment is typically placed at the
head of the operating table
 Monitors are set up on either side of the operating table
for easy viewing
 The instrument table is placed at the foot of the bed for
easy access by the assisting nurse
 Electrocautery and laparoscopic unit are placed where
there is room
Equipment Placement
(continued)
Electrocautery
and laparoscopic
unit typically
placed in these
locations
Anesthetic
equipment
and monitor
for viewing
vital signs
Monitor used
by surgeons to
operate
Monitor used
by assistants
to view
surgery
Instrument table
placed at foot of
bed
Instruments Used
 Laparoscope
 Typically a 30 degree
laparoscope is used for this
procedure
 Dissectors
 5mm or 10mm grasper
 Maryland Dissecting grasper
 Cutting Devices
 Laparoscopic scissors
 Harmonic Scalpel
 Hook Cautery
 Other Instruments
 Suction-irrigation Device
 Extraction Bag
 Clip Applier
Port Placement
 The left adrenalectomy is an operation that requires
three 10mm trocars and an optional fourth 5mm trocar
1. The 1st 10mm trocar is placed 2cm below and parallel to
the costal margin
2. The 2nd 10mm trocar is placed under the 11th rib at the
mid axillary line
3. The 3rd 10mm trocar is placed along the mid-clavicular
line, lateral to the rectus muscle
4. The optional 5mm trocar is placed dorsally at the
costovertebral angle
Port Placement (continued)
10mm trocar
parallel to costal
margin
10mm trocar along
midclavicular line
5mm trocar at the
costovertebral angle
10mm trocar on the
midaxillary line
Procedure: Overview
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Mobilize the colon
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Divide the lienophrenic ligament
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Divide the splenorenal ligament
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Locate, clip, and cut the adrenal vein

Dissect the Lower aspect of the gland
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Locate, clip, and cut the Inferior Adrenal Artery
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Locate, clip, and cut the Middle Adrenal Artery
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Locate, clip, and cut the Superior Adrenal Artery

Dissect the superior, posterior, and lateral aspects of the gland

Remove the Gland through an extraction bag
Procedure
 Mobilization of the colon
 This is done by cutting the
lienocolic ligament
 This will open the operating field
and help to protect the colon
from injury
 Mobilization of the Spleen
 This is achieved by dividing the
lienophrenic ligament
 This allows the surgeon to move
the spleen and start to access the
adrenal vein
Procedure
 Division of the Splenorenal
ligament
 This is the ligament that is holding
the spleen and kidney in close
proximity
 By removing this ligament, the
surgeon is able to enter the proper
field to find the adrenal vein
 Locate, clip, and cut the Adrenal
Vein
 Once located, the surgeon should
trace it back to the renal vein
 Depending on the size of the vein,
typically 3 clips are used
proximally and 2 are used distally
Procedure
 Dissect the lower aspect of the
gland
 Once the adrenal vein is
removed, the lower aspect of
the gland can be dissected
 It is important to carefully
watch for the inferior adrenal
artery
 Locate, clip, and cut the
inferior adrenal artery
 Once this artery is cut, it is
possible to detach the inferior
portion of the gland from the
kidney
Procedure
 Locate, clip, and cut the
middle adrenal artery
 Once this artery is cut it is
possible to dissect the more
medial aspects of the gland
 Use the appropriate number
of clips depending on the size
of the artery
 Locate, clip, and cut the
superior adrenal artery
 Once this artery is cut it is
possible to dissect the more
superior aspects of the gland
 Again, use as many clips as
necessary
Procedure
 Dissect the superior,
posterior, and lateral aspects
of the gland
 Now that the gland has been
detached of its veins and
arteries, it is possible to
dissect it completely
 Remove the gland with an
extraction bag
 It is important to watch out
for and not harm other
organs during this process
Possible Complications
 Hemorrhage
 Cause and Prevention
 Correct any preoperative coagulopathies
 Clip proximal portions of veins at least twice
 Recognition and Management
 Intraoperative hemorrhage identified by excessive bleeding
and may require conversion to an open operation if hemostasis
is not achieved
 Postoperative hemorrhage is identified by monitoring vital
signs and urine output overnight
Possible Complications (Cont.)
 Damage to intraabdominal or retroperitoneal structures
 Cause and Prevention
 Knowledge of anatomy is key!
 Trace veins to point of origin to be sure
 Always know the location of spleen, liver, and pancreas
 Recognition and Management
 Damage to liver or spleen usually results in intraoperative or
postoperative bleeding
 Damage to pancreas can result in pancreatitis
 Often these complications are self managed, but sometimes may
require medical or surgical management
Post Operative Care
 Pain medication given as required (typically only
necessary for a few days)
 Patient is allowed and able to ambulate (move about)
on the same day
 Liquid food intake is started the night of the procedure
 Solid food intake may begin on the first postoperative
day
 The patient can leave the hospital on the second or
third postoperative day