V6-06: Robotic-Assisted Thoracoscopic Transdiaphragmatic Adrenalectomy: A Novel Surgical Approach
In patients who have previously undergone trans-peritoneal or retroperitoneal surgeries, extensive adhesions may limit the feasibility of conventional transperitoneal laparoscopy. Herein, we introduce the technique of robotic-assisted thoracoscopic transdiaphragmatic adrenalectomy (RATTA) in a patient with a history of transabdominal surgeries.
Our patient is a 56-year-old female with a history of clear cell renal cell carcinoma (ccRCC) treated in 2004 with a left hand-assisted laparoscopic total nephrectomy, with negative surgical margins. In 2010, she was found to have enlargement of left retroperitoneal and common iliac lymph nodes and underwent chemotherapy with subsequent retroperitoneal lymph node dissection for a persistent left para-aortic mass. In 2015, she developed a 2.3 cm left (ipsilateral) adrenal nodule and had interval growth of a right lower lung nodule. Biopsy of the adrenal nodule demonstrated metastatic ccRCC. The patient was counseled and elected to undergo concomitant right robotic-assisted thoracoscopic pulmonary wedge resection and left RATTA. After completion of the pulmonary wedge resection by thoracic surgery, the patient was placed in a prone position. A double lumen endo-tracheal tube allowed for single (right) lung ventilation. With the left lung down, an 8 mm (camera) trocar was inserted into the thoracic cavity just superior to the 4th rib and pneumothorax was induced. Under direct vision, two additional 8 mm ports were placed approximately 6 cm on either side of the camera port. A 12 mm assistant port was then placed in a far lateral position. The diaphragm was incised, starting at the left crus and extending laterally through the diaphragmatic muscle exposing the retroperitoneal space and fat. The adrenal gland with mass was identified, dissected from surrounding structures, and extracted. The diaphragm was then closed using Ethibond® suture with PTFE felt pledgets. A 22-Fr chest tube was placed in the thoracic cavity. _x000D_
Operative and post-operative courses were uncomplicated. The chest tube was removed on post-operative day (POD) 2 with no residual pneumothorax. The patient was discharged on POD 4. Pathology confirmed metastatic ccRCC in both the left adrenal and right lung nodules with negative surgical margins.
We present the first described case of robotic-assisted thoracoscopic transdiaphramatic adrenalectomy. This novel technique represents a feasible alternative to transperitoneal or retroperitoneoscopic approaches in patients with previous abdominal and retroperitoneal surgeries.