Clientes Potenciales

Inderbir Gill, MD, MCh

Head, Section of Laparoscopic And Minimally Invasive Surgery Glikman Urological Institute

Executive Director

The Minimally Invasive Surgery Center The Cleveland Clinic Foundation Cleveland, USA

Adrenalectomy

Various techniques have been described for laparoscopic adrenalectomy including transperitoneal, retroperitoneal lateral, retroperitoneal posterior, and recently, employing transthorac trans-diaphragmatic technique in select patients.1 The transperitoneal approach is widely used by laparoscopic surgeons due to the larger working space, and familiar anatomy. However, after Gaur 2 introduced the atraumatic balloon dilatation to create an adequate retroperitoneal working space, retroperitoneoscopy gained in popularity and became the method of choice for lapa- roscopic adrenalectomy in several centers worldwide.3-6

Indications for the retroperitoneal approach

Keeping in mind the unique retroperitoneal location of the adrenal glands, we believe that, in addition to the routine use of the retroperitoneal approach, there are two specific indications wherein the laparoscopic retroperitoneal approach may be superior. First, is the history of previous multiple transperitoneal surgeries and second is morbid obesity. The retroperitoneal approach avoids transperitoneal adhesions and offers a shorter and more direct approach to the adrenal gland, despite the increased amount of retroperitoneal fat in morbidly obese patients.7 Retroperitoneal adrenalectomy can be either performed through the lateral or posterior approach, the former being more commonly used. Herein, the lateral approach is described.

Preoperative patient preparation and positioning

Preoperative serum and urine metabolic panel identifies functional adrenal tumors, which are treated accordingly. Patients with pheochromocytoma are give calcium channel blocker and/or alpha-adrenergic blockers preoperatively and admitted the day before surgery for intravenous hydration. A parenteral broad-spectrum antibiotic is given on call to the operating room. Bowel preparation is limited to clear fluids and two bottles of magnesium citrate administered the evening before surgery. Foley catheter is inserted and anti-embolism stockings are placed on both legs.

Surgical Technique

Retroperitoneal access and port placement: he patient is positioned in the standard 90-degree full flank position

during the retroperitoneal approach. Kidney rest is elevated and the operation table is flexed minimally. Care is taken to pad all positional pressure points. The surgeon and the assistant stand facing the patient’s back during retroperitoneoscopy.

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A 3-port technique is routinely employed. The initial retroperitoneal access is achieved using the open (Hasson) technique.8 A 1.2cm transverse skin incision is created just below the tip of the 12th rib, and flank muscles are bluntly split. The thoracolumbar fascia is exposed and incised to enter the retroperitoneum. Using blunt finger dissection, a retroperitoneal space is developed immediately anterior to the psoas muscle and posterior to Gerota’s fascia. A balloon dilator (PDB, Origin Medsystems, Menlo Park, California) is inserted in the created retroperitoneal space, then inflated with 800cc of air. The balloon is deflated and repositioned higher towards the kidney upper pole, and re-inflated. Such secondary dilation creates an adequate working space along the undersurface of the diaphragm. The balloon is deflated then replaced with a 10mm Bluntip cannula with a 30cc balloon mounted tip (U.S. Surgical, Norwalk, CT) and cinched against the undersurface of the abdominal wall in an air tight fashion. After CO2 pneumoretroperitoneum (15mm Hg) is established, a 300 lens laparoscope is introduced and the anatomical landmarks are examined; the psoas muscle, the anteriorly displaced kidney with its surrounding Gerota’s fascia, and the diaphragm muscle fibers. Under direct vision, two secondary laparoscopic ports are placed. An anterior port is inserted near the anterior axillary line, 3cm cephalad to the iliac crest (10mm port), and a posterior port is inserted at the junction of the lateral border of the erector spinae muscle with the undersurface of the 12th rib (5 or 10mm port).

Left adrenalectomy

The posterior aspect of Gerota’s fascia is incised transversely in the cephalad direction towards the upper pole of the kidney. Dissection is initiated in the area between the aorta and the adrenal gland/upper renal pole to locate and control adrenal branches arising from the aorta. Dissection is continued along the lateral border of the kidney, within Gerota’s fascia and the upper renal pole is identified. The avascular plane between the renal upper pole and the inferior and lateral edges of the adrenal is dissected, and the upper renal pole is completely mobilized within the Gerota’s fascia and dropped posteriorly on the psoas muscle. Dissection is continued along the medial aspect of the upper pole of the kidney towards the renal hilum and the main adrenal vein, branch of the left renal vein, is identified and controlled using 5mm clips, along the infero-medial edge of the left adrenal gland. Sequentially, the adrenal gland is mobilized along its posterior, superior, and anterior surfaces from the psoas muscle, diaphragm, and peritoneum, respectively. Adrenal branches of the inferior phrenic vessels are controlled during dissection of the superior adrenal border. If the main adrenal vein could not be identified earlier, search for it is focused along the inferio-medial adrenal border that is the only residual adrenal attachment at this stage. Antero-lateral retrac- tion of the adrenal gland facilitates dissection and control of the main adrenal vein. The specimen is extracted intact using an Endocatch bag (U.S. Surgical, Norwalk, CT) from the primary port site that may require enlargement accordingly.

edge of the adrenal gland. Dissection is carried cephalad along the venacava until the main right adrenal vein is identified and controlled. The adrenal gland is then mobilized from the undersurface of the diaphragm where the phrenic vessels are controlled. Finally, the plane between the kidney and the adrenal gland is dissected were multiple small arterial and venous branches from the renal hilum entering the adrenal gland along itsinfero-medial border are encountered and controlled.

References

1. Gill, I.S., Meraney A.M., Thomas J.C., et al: Thoracoscopic Transdiaphragmatic adrenalectomy: the initial experience. J. Urol., 165: 1875-1881, 2001.

2. Gaur DD. Laparoscopic operative retroperitoneoscopy: use of a new device. J Urol., 148: 1137-42, 1992 3. Suzuki K: Laparoscopic adrenalectomy: retroperitoneal approach. Urol. Clin. North Am., 28(1): 85-95, 2001 4. Takeda M, Go H, Watanabe R, et al: Retroperitoneal laparoscopic adrenalectomy for functioning adrenal tumors: comparison with conventional transperitoneal laparoscopic adrenalectomy. J Urol., 157:19, 1997 5. Heintz A, Walgenbach S, Junginger T: Results of endoscopic retroperitoneal adrenalectomy. Surg Endosc., 10:633,1996

6. Gill IS. The case for laparoscopic adrenalectomy. J. Urol., 166: 129-136, 2001

7. Fazeli-Matin S, Gill IS, Hsu THS, Sung GT, and Novick AC: Laparoscopic renal and adrenal surgery in the obese patients: comparison to the open surgery. J Urol., 162:665-669, 1999

8. Gill IS, Munch LC, and Grune MT: Access for retroperitoneal laparoscopy. J Urol., 156: 1120, 1996 Nephrectomy

Laparoscopic techniques have been applied to the management of renal cell carcinoma since the early 1990s. After the initial report of Clayman et al in 1991,1 laparoscopic nephrectomy has been proven to be a minimally invasive procedure for the treatment of various benign and malignant renal diseases and it gradually became a reasonable alternative to open nephrectomy. Laparoscopic radical nephrectomy is currently being performed at numerous centers worldwide, commonly by the transperitoneal approach. However, in 1992 Gaur et al reported the creation of an adequate working space in the retroperitoneum by an atraumatic balloon distention method,2 leading to increased interest in laparoscopic nephrectomy via the retroperitoneal approach.3-5 The retroperitoneal approach has potential advantages, since the kidney is a retroperitoneal organ, including early control of the renal vessels and non-violation of the peritoneal cavity, however the main disadvantage is the limited retroperitoneum working space and the perceived difficulty of identifying intraoperative landmarks during the initial surgical experience.

Patient Preparation and Positioning

Preoperative laboratory studies include routine serum electrolytes, complete blood cell count, urinalysis, and urine culture. A parenteral broad-spectrum antibiotic is given on call in the operating room. Bowel preparation is limited to clear fluids and two bottles of magnesium citrate administered the evening before surgery. Foley catheter is inserted to the bladder and anti-embolism stocking is placed on both legs.

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Patient positioning is in the standard 90-degree full flank position. Kidney rest elevation and operating table flexion is useful to maximize the space between the iliac crest and the lowermost rib. Care must be taken to eliminate any pressure point, so foam padding must be used at all bony pressure points and extremities are carefully put in the neutral position.

Surgical Technique

In contrast to transperitoneal laparoscopic nephrectomy, the surgeon and the assistant stand facing the patient’s back. There are several steps that are unique to the retroperitoneal approach, mainly the technique of access and the intraoperative anatomy orientation.6

1. Retroperitoneal access

The initial access is established using an open surgical approach. A horizontal 1.5cm skin incision made at the tip of the 12th rib. Using a pair of S-retractors, flank muscles are bluntly split till the anterior thoracolumbar fascia that is then incised to enter the retroperitoneal space. By gentle finger dissection, a retroperitneal space for the balloon dilator is made between the psoas muscle posteriorly and the gerota’s fascia anteriorly.

2. Balloon dilatation

A working space in the retroperitoneum is created by a PDB dilator balloon (origin medsystems, menlopark, California) inserted into the dissected space and inflated with 800cc of air for adults and 400-600 cc of air for children. The distended balloon displaces the Gerota’s fascia and the kidney anteromedially exposing the posterior aspect of the renal hilum and the adjacent great vessels.

3. Laparoscopic port placement

A 10 mm or 12 mm bluntip cannula is secured as the primary port after the removal of the balloon dilator. Pneumoperitoneum (15mm hg) is created and two secondary ports are placed. Usually 2 and occassionally 3 secondary ports are placed .A posterior port is placed at the angle between the 12th rib and the lateral border of the paraspinal muscles. An anterior port is placed 3 cm cephalad to the iliac crest, between the mid and the anterior axillary lines. Occasionally, a 4th port may be needed. It can be located at the tip of the 11th rib used for traction purposes. It is important to place the ports as further apart from each other as possible to avoid clashing of instruments.

4. Dissection of the renal hilum

Upon initial inspection, the psoas muscle along with one or more of the following landmarks could be identified: Pulsations of the fat covered renal artery, pulsation of the aorta(left side), partially collapsed, bluish venacava (right side), ureter/ gonadal vein, and the lateral peritoneal reflection.

The more anteriorly located renal vein is then identified. It is secured with an EndoGIA vascular stapler. Suprahilar dissection along the medial aspect of the adrenal vessels, including the main adrenal vein that is precisely controlled is done.

5. Specimen mobilization

The whole specimen including the en bloc adrenal gland is now bluntly mobilized from the undersurface of the diaphragm and the retroperitoneal envelope. Inferior phrenic vessels are often encountered along the undersurface of the diaphragm. After the ureter and the gonadal vein are secured, the specimen is completely freed by mobilization of the lower pole of the kidney. The entire dissection remains external to the intact gerota’s fascia and meticulous hemostasis is achieved at all times.

6. Organ entrapment and removal

Using an Endocatch bag (origin medsystems, Menlo Park, CA) the specimen is extracted intact through an enlarged port site incision. If the specimen is too large and presents difficulty in entrapment, an anterior peritoneotomy can be created and both the specimen and the Endocatch are intruded into the cavity for entrapment. Our current routine practice for specimen extraction is a low muscle-splitting Pfannensteil or modified Gibson incision, keeping the extraction extraperitoneal. In suitable female patients, intact specimen extraction from the vagina is feasible.7

7. Exit

Pneumoperitoneum is lowered and hemostasis is checked. Thereafter, the ports are removed under direct vision. All 10 mm port size or larger requires fascia closure.

References

1. Clayman RV, Kavoussi LR, Soper NJ, Dierkes SM, Meretyk S, et al: Laparoscopic nephrectomy: initial case report. J. Urol., 146:278, 1991.

2. Gaur DD: Laparoscopic operative retroperitoneoscopy. J Urol.,148:1137,1992

3. Gill IS, Meraney AM, Schweizer DK et al. Laparoscopic radical nephrectomy in 100 patients: a single center experience from the United States. Cancer. 92(7):1843-55, 2001

4. Abbou CC, Cicco A, Gasman D, Hoznek A, Antiphon P, Chapin DK, Salomon L. Retroperitoneal laparoscopic ver- sus open radical nephrectomy. J Urol.,161:1776,1999

5. Ono, Y., Kinukawa, T., Hattori, R., Yamada, S., Nishiyama, N., Mizutani, K., Ohshima, S.: Laparoscopic radical nephrectomy for renal cell carcinoma: A five year experience. Urology 53: 280-286, 1999.

6. Gill, I. S.: Retroperitoneal laparoscopic nephrectomy. Urol Clin North Am, 25: 343, 1998

7. Gill IS, Cherullo EE, Meraney AM., et al: Vaginal extraction of the intact specimen following laparoscopic radi- cal nephrectomy. J. Urol. 167(1):238-41, 2002

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: Presentation