University of Kentucky Minimally Invasive
Surgery Elective

Adrenocortical tumors related to:
 Cushing’s Disease
 Conn’s Disease
 Virilization of females
 Feminization of males
Pheochromocytomas
Incidentalomas (of sizes greater than 3-4 cm)

 Adrenal tumors greater than 8-10 cm
 Adrenal Carcinoma
 Intracranial hypertension and coagulation issues
 These 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.

 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.

 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.

 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.

 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.

 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

 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.

 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.

 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.

 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.

 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.

 Damage to Liver
 Such 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.

 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 2 nd or 3 rd post-operative day.

 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.

 Right adrenalectomies tend to considered more difficult than left adrenalectomies.
 Common thoughts that support this:
 Retrocaval location of right adrenal gland
 Difficulty of handling the short main adrenal vein that drains into the vena cava.

 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.

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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
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
This however, was statistically different.
Procedural time from left adrenalectomies was, on average, 31 minutes longer than right adrenalectomies.

 Proximity to tail of pancreas
 There 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.

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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.

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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=ot02 en211&s=12&k=2 )
Images from Adrenal Surgery.
( http://www.endocrinesurgery.net.au/laparoscopicadrenalectomy/ )