Page 34 - WJOLS - Laparoscopic Journal

Thawatchai Tullavardhana

necrosis, tumor calcification, evidence of nodal, hepatic, approach, single incision laparoscopic adrenalectomy,
venous invasion. 2,3 NOTES adrenalectomy will be described.
This procedure was performed under general anesthesia.
Indication for Surgery Routine placement of nasogastric tube and urinary catheter
are still requiring.
All of hormonal active adrenal tumor and nonfunctional size,
more than 4 cm, or rapid increase in size adrenal tumor TRANSPERITONEAL APPROACH
should be removed. Laparoscopic adrenalectomy is a surgical
option but should be carefully in large adrenal masses Left Adrenalectomy 3-5,7
(8 cm or greater) that may associated with significant longer Patient position: Lateral decubitus position with the left
operative time, increased blood loss, and longer hospital side up, operative table slightly flexed at the level of the
stay. Indication for laparoscopic adrenalectomy is given in umbilicus and the surgeon and assistant were standing on
Table 1. 3-6 the side opposite to the lesion.
Port site placement: Insertion of Veress needle at 3 cm
Table 1: Indication for laparoscopic adrenalectomy 3 under costal margin at the anterior axillary line then insuff-
lations of carbon dioxide up to 15 mm Hg. Then 10 mm
• Hormonally active adrenal tumor
• Aldosteronoma trocar replaced the Veress needle for a 30 degree 10 mm
• Pheochromocytoma laparoscope. A second 10 mm trocar on the posterior axillary
• Cortisol-producing adrenal tumor line, and a third 5 mm trocar on the midclavicular line.
• Nonfunctioning adrenal lesion greater than 5 cm in size
• Nonfunctioning adrenal lesion with progressive growth
• Solitary adrenal metastasis with negative metastatic survey Operative Approach 3-5,7,8
1. Mobilization of splenic flexure colon by divide
Contraindication splenocolic ligament, leinorenal ligament and dissection

Laparoscopic adrenalectomy has few absolute contra- of splenorenal ligament, lateral peritoneal carried up to
indications as suspected primary adrenal carcinoma that the diaphragm to provide adequate exposure of left
shown aggressive activity as adjacent organ invasion should adrenal gland. Ultrasonic laparoscopic coagulation
be en bloc resection with open surgery. Other of absolute instrument or bipolar cautery can be use during
mobilization of adrenal gland.
contraindication are severe cardiopulmonary disease, 2. Dissection of Gerota’s fascia between upper pole of
uncontrolled pheochromocytoma and uncorrectable left kidney and adrenal gland. Continue dissection to
coagulopathy. Relative contraindications are including medial aspect of kidney for identified of left renal vein.
extensive previous surgery and tumor size more than 3. Meticulous dissection was performed for isolation of
12 cm that may increase risk of bleeding and visceral organ left adrenal vein then clipped and divided. Mobilizations
injury. 3-5 of medial part of adrenal gland out off of the aorta. All
small blood vessels were either clipped or cauterized.
Preoperative Preparation Then continues to superior aspects of the adrenal gland.
Carefully divide the phrenic vessels at this level, avoid
All of patients with hormonal active adrenal tumors should injury to pancreatic tail. The lateral part was mobilized
be carefully preoperative evaluated in blood pressure control, to free adrenal gland from surrounding tissue.
fluid and electrolyte management. Collaboration between 4. Adrenal gland was extracted in a sterile plastic bag
surgeon, endocrinologist, and anesthesiologist are still through the most anterior trocar. Complete hemostasis
necessary. Other preoperative preparations include checking and suture skin incision. Routine drainage is
mechanical bowel preparation, broad-spectrum antibiotic not necessary.
prophylaxis, and deep vein thrombosis prophylaxis. 3-5
Right Adrenalectomy
Operative Technique
Patient position: Lateral decubitus position with the right
There are many surgical approaches to performed side up, operative table slightly flexed at the level of the
laparoscopic adrenalectomy. Including transperitoneal umbilicus and the surgeon and assistant were standing on
approach and lateral retroperitoneal approach, transthoracic the side opposite to the lesion.

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