Right Laparoscopic Adrenalectomy

University of Kentucky Minimally Invasive Surgery Elective

Indications for Laparoscopic Approach

Adrenocortical tumors related to:Cushing’s DiseaseConn’s DiseaseVirilization of females Feminization of males

Pheochromocytomas

Incidentalomas (of sizes greater than 3-4 cm)

Contraindications for Laparoscopic Approach Adrenal tumors greater than 8-10 cm Adrenal Carcinoma Intracranial hypertension and

coagulation issuesThese are contraindications in all

laparscopic sugery. Surgical history of kidney of liver

This is due to an increased risk of adhesions, which would not allow for a transperitoneal approach to be utilized.

Procedure Positioning (Patient)

The patient is placed in a left lateral decubitus position, with the table flexed at the midline. This opens up the operating field.

A cushion is often placed under the left flank of the patient.

The legs of the patient are flexed in order to avoid neuropathy of the lower extremities.

Procedure Positioning (Surgical Team) Both the primary surgeon and the

assisting surgeon stand on the abdominal side of the patient.

The assisting nurse stands opposite of the surgeons.

The anesthesiologist stands at the head of the table.

Procedure Positioning (Equipment) The anesthetic equipment is placed at

the head of the bed. The instrument table is placed at the

foot of the bed next to the nurse. There are monitors on both sides of the

operating table.

Procedure Positioning

Port Placement

There are four 10 mm trocars utilized in the right adrenalectomy.There is one placed at the anterior axillary

line, under the costal margin. Another trocar is placed at the mid-clavicular

line.There two remaining trocars are placed one

either side of the previously placed trocars, still parallel with the costal margin.

Port Placement

Instruments Required

30 Degree Laparoscope DeBakey Grasper Harmonic Ace curved shears Laparoscopic scissors Hook Cautery (sometimes used instead

of Harmonic) Clip Applier Suction-Irrigation Device Extraction Bag

Procedure Mobilization of the

liver: The liver is retracted

with the use of a snake retractor. When doing this, compression of the gallbladder should be avoided.

Once this has been accomplished, the subhepatic peritoneum is dissected. This will free the triangular ligament of the liver.

Procedure The dissection of the subhepatic

peritoneum should allow for the surgeon to see the vena cava and the un-dissected adrenal gland behind it.

Identification of the main adrenal vein:The medial aspect of the gland should dissected

towards the vena cava.The right main adrenal vein should be seen

emptying into the vena cava.Typically, 3 clips are applied, 2 distally and 1

proximally.

Procedure

Procedure

In approximately 10% of cases, there is an accessory adrenal vein that also requires ligation.

If present, it can be seen connecting to the right suprahepatic vein.

It should also be clipped and ligated.

Procedure Identification and ligation of the adrenal

arteries:○ First, the middle adrenal artery should be ligated.

It should be seen originating from the aorta.○ Next, the superior adrenal artery should be

ligated. The adrenal gland should be retracted caudally, making it easier to observe this artery stemming from inferior phrenic artery.

○ Last, the inferior adrenal artery should be ligated. In reflecting the adrenal gland rostrally, this artery can typically be seen branching off of the renal artery.

Procedure

Once all arteries and veins have been clipped and ligated, complete dissection of the superior, medial, and inferior portions of the gland can take place.

Following this, an extraction bag is utilized to carefully remove the gland from the patient.

Potential Complications

Damage to LiverSuch injury can occur during retraction or

during dissection itself. Damage to Vena Cava

This is the leading cause of conversion to open surgery.

If the lesion is less than 2 mm in size, then it is quite possible that compression and coagulating agents will suffice.

Post-operative Care

The patient may ambulate on the day of surgery.

By the night of the surgery, the patient is allowed fluids.

On the first post-operative day, the patient is allowed to consume solid food.

Release from hospital typically occurs on the 2nd or 3rd post-operative day.

Difficulty of the Procedure Because of the retroperitoneal location of

the adrenal glands, dissection of peritoneum and other fascia often account for the majority of operation time.

This extensive dissection can be a hassle. To compound the problem, a survey discovered that, on average, general surgery residents only received exposure to 1.5 adrenalectomies during their residency.

Differences of Right and Left Adrenalectomies Right adrenalectomies tend to

considered more difficult than left adrenalectomies.

Common thoughts that support this:Retrocaval location of right adrenal glandDifficulty of handling the short main adrenal

vein that drains into the vena cava.

Study Concerning Differences in Right and Left Adrenalectomies

To investigate this matter, a retrospective study of 163 laparoscopic adrenalectomies was performed.

The study was performed over an 8-year period, following 27 surgeons at 9 Southern California Kaiser Permanente Hospitals.

109 of the surgeries were left adrenalectomies, while 54 were right adrenalectomies.

Outcomes Blood Loss

The average estimated blood loss of the left adrenalectomies was 113 mL, ranging from 2 to 3000 mL.

The average estimated blood loss of the right adrenalectomies was 84 mL, ranging from 10 to 700 mL.

This was shown to not be statistically different. Procedural Time

This however, was statistically different.Procedural time from left adrenalectomies was, on

average, 31 minutes longer than right adrenalectomies.

Plausible Explainations:

Proximity to tail of pancreasThere was an 8% rate of distal pancreatic

injury reported. Complexity of splenic vasculature Required dissection of left renal hilum Less mobilization is required for right

colon than for the splenic flexure.

Retroperitoneal Approach? In a study comparing retroperitoneal approach

with the transperitoneal approach, it was found that the operation time for the retroperitoneal approach ranged from 290 to 330 minutes.

In comparison, the transperitoneal approach averaged 140 minutes in duration.

Why? It was found that maneuvering of the surgical tools

proved difficult because of a smaller operating field.In addition, less of the adrenal gland is exposed in

this approach.

References Laparoscopic Right and Left Adrenalectomies: Surgical

Endoscopy. (http://www.ncbi.nlm.nih.gov/pubmed/8703150)

Differences in Right and Left Adrenalectomies: Journal of the Society of Laparoendoscopic Surgeons. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3041033/)

Laparoscopic Right Adrenalectomy: WebSurg. (http://chapters.websurg.com/technique/index.php?doi=ot02en211&s=12&k=2)

Images from Adrenal Surgery. (http://www.endocrinesurgery.net.au/laparoscopic-adrenalectomy/)