and Francisca Yankovic1
(1)
Department of Paediatric Urology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK
Abstract
Laparoscopic adrenalectomy is the standard of care for the surgical excision of the adrenal gland, adrenal tumours, and adrenal biopsy. The choice between laparoscopic and retroperitoneoscopic approaches is dictated by the experience of the surgeon [1]. Patients requiring surgery for a phaeochromocytoma, adrenal adenoma, adrenal adenocarcinoma, Cushing’s syndrome, neuroblastoma, or an incidentaloma are all candidates for this approach. There are no absolute contraindications to the minimally invasive (MI) approach, but for neuroblastomas and other adrenal neoplasms, care must be taken to maintain the principles of cancer surgery. Relative contraindications include previous surgery of the liver or kidney, large tumours (>8–10 cm in diameter), or coagulation disorders.
Keywords
RetroperitoneoscopicAdenomaAdrenalLaparoscopic34.1 General Information
Laparoscopic adrenalectomy is the standard of care for the surgical excision of the adrenal gland, adrenal tumours, and adrenal biopsy. The choice between laparoscopic and retroperitoneoscopic approaches is dictated by the experience of the surgeon [1]. Patients requiring surgery for a phaeochromocytoma, adrenal adenoma, adrenal adenocarcinoma, Cushing’s syndrome, neuroblastoma, or an incidentaloma are all candidates for this approach. There are no absolute contraindications to the minimally invasive (MI) approach, but for neuroblastomas and other adrenal neoplasms, care must be taken to maintain the principles of cancer surgery. Relative contraindications include previous surgery of the liver or kidney, large tumours (>8–10 cm in diameter), or coagulation disorders.
A large body of literature supports MI adrenalectomy in adults, but the experience in children is relatively sparse. The transperitoneal route is used more widely and offers a larger working space [2]. The retroperitonscopic approach provides direct access to the adrenal gland and more direct visualization of the adrenal vein. It also avoids colonic mobilization and minimizes the risk of injury to hollow viscera and the potential risk of adhesion formation. However, the reversed orientation of the kidney and hilum, combined with a significantly smaller working space, may make this approach difficult to master [3]. This chapter describes the retroperitoneoscopic MI adrenalectomy.
34.2 Working Instruments
Primary camera port: 6-mm Hasson
Secondary 5-mm ports (×2)
30° 5-mm laparoscope
Kelly forceps (×2).
Metzenbaum scissors
Laparoscopic hook
LigaSure™ (Covidien) or 5-mm endoclips
Endopouch® (Ethicon Endo-Surgery) for specimen retrieval
34.3 Relevant Anatomy
The left adrenal gland usually is smaller than the right and lies at the medial aspect of the upper pole of the left kidney. The arterial supply is derived from three adrenal arteries: superior (left inferior phrenic artery), middle (aorta), and inferior (left renal artery). The main left adrenal vein joins with the left inferior phrenic vein to drain into the left renal vein.
The right adrenal gland is located at the medial aspect of the upper pole of the right kidney, behind the vena cava in a very deep and high position. The arterial supply derives from the superior (inferior phrenic artery), middle (aorta), and inferior (right renal artery) adrenal arteries. The main right adrenal vein drains into the posterior lateral aspect of the vena cava after a short horizontal course. Variant venous anatomy is more frequent in the right adrenal gland, being encountered in about 10–15 % of patients [4].
34.4 Positioning, Port Siting, and Ergonomic Considerations
The patient is positioned fully prone with the chest and hips raised, allowing the abdomen to be free (Fig. 34.1a). It is important to place the patient at the lateral edge of the table, to allow unrestricted movements of the laparoscopic instruments. Once the position is ready, the patient should not be moved. Before skin preparation, the landmarks are drawn (Fig. 34.1b).
Fig. 34.1
(a) Position for right adrenalectomy. (b) Landmarks: 12th rib (1), sacrospinalis muscle (2), iliac crest (3)
The working ports are placed using the landmarks: The camera port is placed lateral to the sacrospinalis muscle, midway between the 12th rib and the iliac crest; the first instrument port is placed 2–3 cm lateral to the tip of the 12th rib, and the second instrument port is placed medial to the camera port (Fig. 34.2a). The camera port is placed using the technique described by Gaur [5], with a balloon made from the middle finger of a size 8 surgical glove tied to a Fr 12 Jacques catheter (Fig. 34.2b).
