Imaging demonstrates a multinodular 5cm–6cm large cyst-like mass in the region of the left adrenal, clinically confirmed as pheochromocytoma.
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CT findings
![CT findings]()
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Trocar positioning
![Trocar positioning]()
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.
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Freeing the descending colon
![Freeing the descending colon]()
Soundsettings Pull the descending colon mediad and incise the retroperitoneum in the avascular plane anterior to the left kidney.
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Opening the prerenal space
![Opening the prerenal space]()
Soundsettings 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.
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Dissecting the spleen off the diaphragm
![Dissecting the spleen off the diaphragm]()
Soundsettings Now transect the suspensory ligaments tying the spleen to the diaphragm, which then allows en blocmobilization of the spleen and pancreatic tail.
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Exposing the superior left retroperitoneum
![Exposing the superior left retroperitoneum]()
Soundsettings Under gentle traction first mobilize the spleen and then the pancreatic tail step by step mediad.
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Accessing the adrenal
![Accessing the adrenal]()
Soundsettings 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.
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Mobilizing the adrenal tumor
![Mobilizing the adrenal tumor]()
Soundsettings 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).
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Transecting the central suprarenal vein
![Transecting the central suprarenal vein]()
Soundsettings 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.
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Transecting the arterial blood supply
![Transecting the arterial blood supply]()
Soundsettings Dissection of a small arterial tributary will expose the main vessel. Seal both vessels with 3 titanium clips each.
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Removing the entire adrenal
![Removing the entire adrenal]()
Soundsettings First transect the clipped arteries. Now, with the Ultracision® release the adrenal with its tumor from the perirenal fat.
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Retrieving the specimen and placing a drain
![Retrieving the specimen and placing a drain]()
Soundsettings After scrutinizing the field for hemostasis remove the adrenal tumor in the retrieval bag.
Note the unchanged adrenal remnant on top of the tumor.
Sectioning the tumor demonstrates multiple medullary tumors of different size.
Place an Easy Flow drain. And finally return the dislocated spleen to its original position.
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Wound closure
![Wound closure]()
After removal of the trocars suture the fascia and skin at their incisions. Anchor the Easy Flow drain with a suture.
