Right Laparoscopic Adrenalectomy

Right Laparoscopic
University of Kentucky Minimally Invasive
Surgery Elective
Indications for Laparoscopic
Adrenocortical tumors related to:
 Cushing’s Disease
 Conn’s Disease
 Virilization of females
 Feminization of males
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 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.
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
Procedure Positioning (Surgical
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
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
 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
Mobilization of the
 The liver is retracted
with the use of a snake
retractor. When doing
this, compression of the
gallbladder should be
 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
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
○ 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
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 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.
Post-operative Care
The patient may ambulate on the day of
 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
Differences of Right and Left
Right adrenalectomies tend to
considered more difficult than left
 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.
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
 109 of the surgeries were left
adrenalectomies, while 54 were right
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
Plausible Explainations:
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.
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
 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.
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.
Laparoscopic Right Adrenalectomy: WebSurg.
Images from Adrenal Surgery.
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