From Win et al., Described the first laparoscopic adrenalectomy (al), this minimally invasive surgical approach almost replaced open adrenalectomy in handling small and medium-adrenal lesions. Benefits include shorter hospital, reduced postoperative pain, better recovery time and better cosmetic result. In addition, difficulties with open surgical exposure and the small size of the adrenal gland makes the body ready for minimally invasive techniques. Anatomical position of the adrenal glands leading to a series of laparoscopic approach including rear or side retroperitoneal, transthoracic and lateral transperitoneal. This article describes the various surgical techniques used in Los Angeles are reviewed. preoperative preparation
We do not realize such a systematic mechanical bowel preparation before in Los Angeles. preoperative antibiotic prophylaxis is administered before the procedure. and anti-thrombotic stockings are placed in the waiting room, before induction of anesthesia, and sequential compression device used in the case. Usually, setting the gastric tube and Foley catheter before starting the procedure and then retreat to its conclusion.
Transperitoneal surgical approach
Transperitoneal offers the greatest view of the operative field, thus reducing intraoperative injury and ensure minimal morbidity. In addition to the control tower and the gas fan intra-abdominal pressure of 15 mmHg, using 0 ° and 30 ° and 10 mm laparoscope. 12 mm and three 5 mm trocar is generally used. Our instruments include vacuum suction, ultrasonic scissors curve, link at right angles, bipolar forceps, Endoshears monopolar, 5 mm Hem-o-lok (Weck) clip-applicator Endopouch specimen bag and spacing peer. It is the establishment of pneumoperitoneum using a Veress needle technique. It can also be used Hasson open procedure peumoperitoneum.
After induction of anesthesia, the patient is in the lateral position with the highest affected side of about 60 °. The patient is on the sack beans, which helps keep the patient in place. The soft roll is placed under the opposite armpit. The hands are filled with padding. Contralateral arm is usually placed on a table hand reinforced with pillows or soft padding, and secured with tape. Ipsilateral hand tied similarly arm contralateral way, but can also be supported by a metal support in the form of L is fixed to the table. It has been discovered that the curvature of the plate is not necessary for transperitoneal approach. The patient is fixed to the table with two inches of tape at the bottom of the legs, the thighs, pelvis and chest, allowing the rotation of the table top during operation. In addition, the potential for conversion to open surgery should be considered when setting up.
Retroperitoneal, lateral surgical approach
Retroperitoneal approach has the advantage of avoiding intra-abdominal organs and allow direct access to the adrenal. This technique does not provide exposure to the same procedure attempts transperitoneal and tumors greater than 7 cm not suitable for this technique. In addition, there is a general lack of anatomical landmarks, which makes it more difficult to dissect. The main indicator of retroperitoneal approach was before the surgery with intra-abdominal adhesions. Our institution has adopted a similar method described in Sung et al method.
Patients were placed in the lateral decubitus position. To fully develop the operating space between the ridge 12 and the pelvic bones, the table folds. The aim is to expand the gap between the coastal margins and pelvic bones. All extremes meticulously padded and attached as described above transperitoneal adrenalectomy to avoid injury neuromuscular. Surgeons should be cautious when located in the lateral decubitus position for extended periods of time.
Most surgeons use open Hasson technique for retroperitoneal approach. Dermal 2 cm incision approximately 2 cm below the lower edge of the rib 12th underlying muscle layers are completely separate and retroperitoneal entered dividing the thoracolumbar fascia layer with hemostat. Carefully finger dissection, a potential space created under the belt to allow the balloon dilator. About 800 ml of air is blown into the flask to create a working space. The device is then deflated and advanced with brain psoas level retroperioteum the diaphragm. The balloon is inflated and deflated and the second time, and then removed. This can be useful to put a laparoscope into the cavity at the same time working to help in the enlargement process. 10 mm trocar is inserted and established pneumoperitoneum. Two additional ports are used 5mm. Trocar is located midway in the front axillary line between the ribs and pelvic bones. The third port is located in the back between the ribs 12 and the pelvic bones along the side edge of the sacrospinous. The fourth port (5 mm) was inserted through the insertion cephalic kidney and placed at the first connection of the front axillary line. Psoas is an important step back to make sure the kidneys and adrenal glands are located on the front.
After placing the port and create the space for world governance, shock rear fascia Gerot upper renal pole with a harmonic scalpel. By extending the dissection around the upper surface of the kidney, adrenal gland, which calls remain stationary, allowing the renal glands. Using the laparoscope 30 ° greatly facilitates this operation. The surgeon must consider at this stage renal vessels accessories that can be injured during this phase.
Ports are located in the same mode left mirror image. Again, the fascia layer to invest in the right kidney is open transverse to the upper half of the kidneys and continuous circumferential dissection creates the potential space between the adrenal gland and kidney. At this stage of the IVC is identified and dissected superiorly extending along the lateral edge of the vein. The right adrenal vein probably find him at this stage, it branches inside the gland. The vessel is again divided between clips. Mobilizing says the adrenal gland is completed similarly to the left with the care given to vessels less than phrenic recognition, while dissecting along the underside of the membrane. In rare cases, the tooth fan is used to move the liver medial to allow correct display and workspace.
Bilateral laparoscopic adrenalectomy
Bilateral adrenalectomy is provided to bilateral adrenal hyperplasia associated with Cushing's syndrome, which is resistant to treatment. Surgery may also be needed for bilateral adrenal neoplasms. Patients who show increased cortisol excess fat, and some argue that the laparoscopic approach in these patients is most appropriate. In addition, patients with Cushing's syndrome have an increased mortality rate due to poor wound healing and increased risk of thromboembolic events. Before surgery should be taken to optimize these people medically. Wherein each of the techniques described above may be used, typically use lateral transperitoneal approach. Tumor or severe side should do first. After completing the one hand, the patient can go back and re-wrapped the opposite side.
Laparoscopic partial adrenalectomy
From Jeschke et al., A showed the safety and efficacy of laparoscopic partial adrenalectomy for aldosteronomas the laparoscopic approach is increasingly used for adrenal procedures savings. In order to preserve adrenal function in patients with adrenal lesions of the laparoscopic approach provides better visibility and the ability to distinguish normal parenchyma tumor. Home surgical technique is closely following the process above. After blowing and careful exposure to the adrenal glands, trying to remove a thin adrenal surrounding healthy tissue of the adrenal nodules crown, using the harmonic scalpel. adrenal vein is left intact except for a systematic location of the tumor requires bipolar coagulation. It is important to minimize dissection preserve adrenal tissueto remaining connective vascularization. The importance of correctly identifying the boundaries of adrenal tumors before dissection can not be emphasized enough. Intraoperative ultrasound using a flexible tube laparoscopic adjustable 10 mm is useful in showing the extent of the tumor. Bipolar coagulation and fibrin glue or Floseal (Baxter) is used to obtain hemostasis after partial adrenalectomy.
Laparoscopic adrenalectomy is safe and effective for surgical removal of the adrenal tumors techniques. This minimally invasive approach offers clear advantages compared with open resection. With careful patient selection and meticulous surgical technique should expect positive results.