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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:
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.
Surgeon Inexperience
Surgical history of kidney or liver
Increase risk of adhesions making transperitoneal approach impossible Make for much riskier dissections
Length of Stay
Morbidity Rates (30 day)
9.4 Days
17.4%
4.1 Days
3.6%
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
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
Instruments Used
Laparoscope
Typically a 30 degree laparoscope is used for this procedure
Cutting Devices
Laparoscopic scissors Harmonic Scalpel Hook Cautery
Dissectors
5mm or 10mm grasper Maryland Dissecting grasper
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
Procedure: Overview
Mobilize the colon
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
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
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
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
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
Possible Complications
Hemorrhage
Cause and Prevention
Correct any preoperative coagulopathies Clip proximal portions of veins at least twice
The patient can leave the hospital on the second or third postoperative day