V911: Laparoscopic right-adrenalectomy for pheochromocytomas: step-by-step
VideoIntroduction and Objectives
Adrenalectomy for pheochromocytoma is associated with significant hemodynamic changes. Safe surgery requires a quick, precise approach to the procedure. We present a step-by-step video of the technique for laparoscopic right adrenalectomy.
The patient is placed in a 70 degree oblique left-lateral position. Pneumoperitoneum is obtained using a Veress® needle and the primary camera port is placed cranial and lateral to the umbilicus. Two working ports are placed below the costal margin in the midclavicluar and anterior axillary lines while the liver retraction port is placed below the xiphisternum in the midline. As the first step, a right angled incision is made in the peritoneum, lateral to the vena cava and extending on to the under surface of the liver. A superior adrenal vein that arises from the phrenic vein branches is frequently found. This vessel can easily be missed and avulsed and should be actively sought, clipped and divided. The peritoneal incision lateral to the cava is extended inferiorly and laterally between the kidney and the adrenal, isolating the tumor. The medial aspect of the tumor is then dissected, separating it from the vena cava. A number of small veins may be encountered here which must be controlled. At all times, the tumor is not directly held but is retracted through gentle traction. Next, the tumor is mobilized from the undersurface of the liver, the psoas muscle and lateral peritoneal attachments. The operative field is inspected at low intra-peritoneal pressure to confirm hemostasis and the specimen is extracted.
The basic principles of adrenalectomy for phecohromocytoma are minimal tumor handling to avoid catecholamine surge, early release from the liver to minimize respiratory movements and traction bleeding, early vascular control and confirmation of hemostasis. In bilateral tumors, an attempt can be made to preserve a part of the normal gland.
Laparoscopic adrenalectomy for pheochromocytomas can be safely performed by adhering to basic surgical principles.