Left adrenalectomy, laparoscopic

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  • Adrenal anatomy – glandulae suprarenales

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    (1) Adrenal gland, (2) Left kidney, (3) Abdominal aorta (4) Inferior phrenic arteries, (5) Superior suprarenal arteries, (6) Middle suprarenal arteries, (7) Inferior suprarenal arteries, (8) Aberrant accessory renal artery, (9) Renal arteries, (10) Testicular arteries

    The paired adrenals are located superior to the superior poles of the kidneys, separated only by a thin layer of fatty tissue. Since they are flattened along the posteroanterior axis, they have clearly distinct anterior and posterior aspects. The left adrenal resembles a crescent, while the right gland is mitral shaped. The anterior aspect of the left adrenal is completely covered with peritoneum, while the latter covers only the inferior aspect of the right adrenal. The posterior aspect of both adrenals abuts the lumbar aspect of the diaphragm.

    The topography of the right adrenal relates to the liver and inferior vena cava, while the left adrenal reaches the spleen and is separated from the posterior gastric wall by the lesser peritoneal sac. Both adrenals are located at about the level of the 11th/12ththoracic vertebra and enclosed by a vascularized capsule of connective tissue made up of collagen fibers and smooth muscle cells. Adult adrenal glands weigh about five to seven grams.

    Blood supply

    1. Arteries
    Inferior phrenic artery →Superior suprarenal artery
    Aorta →Medial suprarenal artery
    Renal artery →Inferior suprarenal artery
    There are numerous variants!

    2. Veins
    In each adrenal the venous blood is collected in the central vein which exits the gland through the suprarenal hilum and becomes the left (or right) suprarenal vein.
    Right suprarenal vein →Inferior vena cava
    Left suprarenal vein →Renal vein

    3. Lymphatics

    The lymphatics exiting the adrenals primarily parallel the arteries. The primary lymph nodes of the adrenals are the para-aortic and lumbar lymph nodes. Some lymphatics traverse the diaphragm and drain into the posterior mediastinal lymph nodes.

  • Pathophysiology

    Tumors of the adrenal glands are either primary neoplasias or metastases.

    Primary adrenal tumors arise from the adrenal cortex or medulla. Some but not all of them produce hormones.

    Adrenal neoplasias actively producing hormones correlate with the corresponding zones in the adrenal cortex or medulla. Tumors of the glomerular zone result in primary aldosteronism (Conn syndrome) and those of the fascicular zone in hyperadrenocortisolism (Cushing syndrome), while neoplasias of the reticular zone produce an overabundance of sexual hormones. Tumors of the adrenal medulla are called pheochromocytomas.

    Cortical and medullary tumors of the adrenal gland may be benign or malignant, with the former by far predominant. In cortical tumors the probability of malignancy correlates with the size. In pheochromocytomas there is no such direct relationship between the tumor size and rate of malignancy.

    Histological differentiation between benign and malignant adrenal tumors is hampered by their cellular polymorphism and becomes impossible in pheochromocytomas. Here, only the presence of distant metastasis suggests the malignant nature of the tumor.

    The gross anatomy of adrenal tumors presents with a homogeneously yellow-brownish cut surface, while pheochromocytomas appear as greyish-red, often also cystic, neoplasias.

    Primary tumors of the adrenal glands include myelolipomas, adrenal cysts and ganglioneuromas. Almost without exception these are benign.

    Adrenal metastasis is primarily seen in cancer of the lungs and kidneys and in malignant melanoma.

    Primary lymphomas are extremely rare.

    While the etiology of most primary tumors of the adrenal cortex remains unclear, more than 20% of pheochromocytomas arise from genetic causes (e.g., multiple endocrine neoplasia type 2).

  • Lukaskrankenhaus Neuss

    Dr. Katharina  Schwarz

  • Lukaskrankenhaus Neuss

    Prof. Dr. med. Peter Goretzki

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 21.05.2012
  • Lukaskrankenhaus Neuss

    Dr. Katharina  Schwarz

  • Lukaskrankenhaus Neuss

    Prof. Dr. med. Peter Goretzki

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  • CT findings

    78-4

    Imaging demonstrates a multinodular 5cm–6cm large cyst-like mass in the region of the left adrenal, clinically confirmed as pheochromocytoma.

  • Trocar positioning

    78-5

    Perform medial 2cm long minilaparotomy in left upper quadrant for the trocar of the laparoscope and then initiate pneumoperitoneum. After exploration of the abdominal cavity introduce two more working trocars – one 5mm trocar in the left upper quadrant and a Versa-Port V12 anterior to the 11thrib.

  • Freeing the descending colon

    78-6

    Pull the descending colon mediad and incise the retroperitoneum in the avascular plane anterior to the left kidney.

  • Opening the prerenal space

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    Approach the left adrenal laterally by freeing the left colic flexure step by step from the retroperitoneum until large parts of the anterior aspect of the Gerota fascia and renal capsule have been exposed.

    Note:In slender patents it may become difficult to spare the Gerota fascia.

  • Dissecting the spleen off the diaphragm

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    Now transect the suspensory ligaments tying the spleen to the diaphragm, which then allows en blocmobilization of the spleen and pancreatic tail.

  • Exposing the superior left retroperitoneum

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    Under gentle traction first mobilize the spleen and then the pancreatic tail step by step mediad.

  • Accessing the adrenal

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    Carefully lifting the pancreatic tail craniad access to the left adrenal is gained at the end of the pancreatic tail posterior to the spleen and the adjacent gastric wall. Now, starting laterally first expose the adrenal by carefully transecting the small, primarily venous tributaries. This is carried out with the Ultracision® harmonic scalpel and includes exposing the lateral esophageal hiatus and left crus of the diaphragm.

  • Mobilizing the adrenal tumor

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    Expose the adrenal from its medial aspect. Delineate the medial margin of the adrenal tumor anterior to the aorta. The inferior margin borders on the renal vein. Gradual dissection from caudad to cephalad will expose the dual arterial blood supply with the inferior and superior renal artery. Carry out this dissection with the Ultracision® harmonic scalpel once again.

    Note:18% of all patients have more than one renal artery on each side (accessory vessels).

  • Transecting the central suprarenal vein

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    First, between clips transect the superior suprarenal artery arising from the inferior phrenic artery. Now expose the renal vein and the central suprarenal vein. The suprarenal vein typically exits the adrenal gland at its anterior aspect and crosses the renal artery. Clip the suprarenal vein close to the tumor with 3 titanium clips and transect it with the Ultracision® between the second and third clip.

  • Transecting the arterial blood supply

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    Dissection of a small arterial tributary will expose the main vessel. Seal both vessels with 3 titanium clips each.

  • Removing the entire adrenal

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  • Retrieving the specimen and placing a drain

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  • Wound closure

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  • Lukaskrankenhaus Neuss

    Dr. Katharina  Schwarz

  • Lukaskrankenhaus Neuss

    Prof. Dr. med. Peter Goretzki

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  • Intraoperative complications

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  • Postoperative complications

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  • Klinikum Ingolstadt

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  • Literature summary

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  • Current trials

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  • References on this topic

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  • Literature search

    Literature search under: http://www.pubmed.com