Left Laparoscopic Transperitoneal Adrenalectomy for Aldosteronoma

CHAPTER 1

Hi. My name is Richard Hodin. I'm asurgeon at Massachusetts General Hospitaland chief of our endocrine surgery unit.We're going to be doing a laparoscopic left adrenalectomytoday for apatient with an aldosteronoma.This is a 48-year-oldwoman who has long-standing hypertension,has been on multiple medications,and was also noted to have hypokalemia,and eventually was sent to an endocrinologist whodid the appropriate blood test and biochemicallyconfirm that she had hyperaldosteronism with asuppressed renin level andand was therefore diagnosed with aldosteronism.And then she had a CAT scan.The CAT scan showed a normal right adrenal gland anda sort of the lobulated left adrenalgland with just a very small - whatappeared to be an 8-mm nodule -not a huge mass but consistentwith a small lesion that we often see with aldosteronomas.She went on to have adrenal vein sampling done,and this confirmed thestep up on the left side with a very high all aldosterone levelcompared to the control cortisol, compared to the right side, sothe ratio is quite high - over three -and therefore that confirmed that this was almost certainly aleft-sided aldosteronoma.And we are going to remove the adrenal gland today,again, with a laparoscopicleft adrenalectomy.So this is the CAT scan, andit shows as we come down,a smalladrenal nodule -not huge butclearly something abnormal in the adrenal gland.The right side on these images you can hardly see.It’s just a normal -a normal right-sided adrenal.So with that imaging and confirmation with theadrenal vein sampling, we’reconfident that this patientshould have her left adrenal gland removed.

So the patient is being anesthetized now and a Foley catheter isbeing placed.I do a full lateral decubitus,almost 90 degrees, perhaps a little lesslike 80-degree tilt, andthen we're going to use the transabdominal,transperitoneal laparoscopic approach.

I do aleft paramedian open laparoscopictechnique, so through the left paramedian position,we’ll place the Hasson trocarand thenobtain a pneumoperitoneum,and then we will place an 11-mm trocar in theepigastrium and two 5-mm trocarsalong the left costal margin or alittle below that. And then we willmobilize things - mobilize the coloninferomedially - the spleen and tail of the pancreas to thepatient's right and thencircumferentially dissect the adrenal glandaway from all of his attachmentsand find the adrenal vein, which we will clip.And then the gland will beremoved, placed into an Endo Catch bag, and bring it out.

CHAPTER 2

So that's the plan, and we'll get started soon.Okay, we do a wide prep of theabdomen, chest, and back region just in casewe have to make a open incision, and eventheoretically, although I'm sure it won'thappen,we would be able to do a thoracoabdominal incision.That's really not for this kind of case.I usually try to have the umbilicus visualized. We're going to goin a paramedianspot - so we’ll be above the umbilicus, but justit helps with visualization.

So here is the ribs,and what we're going to do is a paramedian,usually up a little bit superiorto the umbilicus.If there's kind of - if there's a panis, I usually let itdrop down and goa little bit lateral, and then there'll be some epigastric port.And then two 5-mm trocars out there.

CHAPTER 3

Can we have the local anesthesia?So I like to use preemptiveanalgesia, right?Whichapparently works better than if you do it at the end. We do it atthe end also, butI do it before.So we'll take the Bovie and sponge.So just use cut andmake an incision there.Hold on one second.Let's make it a little bit longer going up.We’re gonna -okay. And then now coag.I'll take twoRichardson's, please.Okay so,let's go like this.Do you have a Schnidt please, or a forceps?Yeah, use the corner.Yep.Okay so there - here hold this for me.Can I get aforceps please - the long DeBakeys?There's no DeBakey in here.Oh, okay. Just a Schnidt is fine.So there's the anterior sheath.We’ll take a Bovie and just small incision, small.Up and down. Yep.Okay - stop. That’s enough.Okay, can we have 0 Vicryl, please?So we’ll put stay stitches in.So go outside in, inside out.Outside in...We’ll take a snap and scissors, please.Grab that with the needle driver.Grab it with the needle driver - the needle.I’m going to cut it.Okay.Snap, scissors, please. You can cut it.And then another stitch.Okay, let me do this again here.Okay, can you get the needle out, you see it?You can cut that, yep.Okay, snap.And I'll take two S-retractors and another Schnidt, please.Okay, so we have stay stitches in theanterior sheath. Hold on, you’re gonna -forget that - you can use this.On very thin patients of course, this is very easy.Okay, take that out for a minute.Okay, so I'm going to have you hold this one down here,if you wantto grab - that's fine, okay -next to mine. Yep. Knife, please?Can you hold that or not?Okay knife.And then we're going to take Hasson in just a minute.And then I’ll just take this for a second. That's in there - see it? Hold like that.Yep. Hold it like that.Once I get access, especially...Hold like that.Okay.And then hold up the other stitch.Try to get a little bit of purchase.Okay, and then we'll secure this around here.You can put it up - it's okay up here, yep.We’ll take high flow on the CO2, please.And then,can we have the room lights off?And if you can put thepressure up - set it at 17 - 1.Looking in, we've got some adhesions - somesort of extra attachments of the omentum up here, unfortunately.So we’ll have to take those down.We'll come in with ourepigastric port. Okay so hold right here.Can I have the local anesthesia - yep.Okay knife, please.And then the 11-mm trocar.Okay.Can I get the harmonic, please?Let's start taking some of these down and we’ll get better access.

I wonder if from the other side it wouldn't be easier though.Do you put one right here?Yeah, no, we'll do that, but...It's just I'm hitting her shoulder.I'm hitting the shoulder, but that's all right.So she’s socked in herein the left upper quadrant for some reason -not sure why.I'm sure it has nothing to do with her adrenal, but -I'm not sure what.She hasn't...Diverticulitis?Let's see, yeah, obviously it would be... Or Trauma.An unusual place for diverticulitis, but...I want you to really angle it up. It's way up in the...Okay, let me just get this thing right here.So what we are going to do nowis put in the other two trocars -at least the lateral one first, solooking up towards the left upper quadrant.The colon - we obviously stay away from that - why don't youbring it out there. Sure.Horizontal or vertical?Horizontal, 5 mm.And then...Good, and then why don't you to take this last adhesion down,and I'm going to take the fan retractor, please.So let's take another - put another trocar in, which will beabout here, halfway between theparamedian and the latter one.Okay, I'll take the fan retractor,just hold the scope for one minute, please.

CHAPTER 4

So let's nowcontinue by - that's fine - taking down thecolon - the splenic flexure of the colon.We want to get that...Let's take these last attachments down up there.Down there, yep.Let's get this stuff up here.Nikolai, can you open up every once in awhile tovent the port. Yeah, sure.Okay, hold on.Okay, go ahead.Okay so now,we don't really have to -we may want to drop it down a little bit more - justright there - just to give us a little more mobility,but then the key thingis next - is to get between thecolon and the kidney.All right, so let's see, if you hold a scope for just a minute...Sure thing.So,you see the colon there, right?And here's kidney that I'm sort of pressingon. So I open up this -let's get thatbleeder before...I go like this - you take your other instrument and just -take your other instrument, please.And -just push on the kidney back a little bit,so I push one direction - you push the other direction,and that opens up the plane.So here down - look where I am down here - nope - no, that’s -you want to go - hold on one second.Right in there, and you push opposite me,and there's the plane right there.Go ahead.No, above.Above.Where you were - just right - get that stuff.Right there - yep.That's it.So it's an avascular plane between thekidney and the colon,and you go right in there, and you follow that.And that will lead us to where we're gonna - so then I come back andwe still have to get the colon out a little more - see this?Yep. Go ahead -just get that.The harmonic is...Right there. Okay.

CHAPTER 5

Sowe're just getting, again, push the kidney a little bit. Yep.There you go. That's the spot just the - yep.It’s all fizz fuzz. And then you comethere, and you push the other direction, and it opens itright up. There you go.Get a little towards you more.Yep - and you’re a little too deep. Just get the fizz fuzz.I mean you should be right in here where my instrument is -you see it?You can almost see through it.Right there - yes. That's what you want. Yep, that's the spot.If you're in the right spot, it just completely unfolds.Okay.Go ahead and push.See it? Yep.Go ahead.Careful. You see what - what'sunderneath me there?What is that,Right there?So it’s either - that’s pancreas. That's pancreas. Yep.So, now you can come up on top now. You see that?Get stuff up on top right there.Oh this stuff on top? Okay. Yep.And then you're going to follow thisto get behind the spleen next.That? Yep, go ahead. Keep going.See how we're going to head up,and that's how we're going to get the spleen mobilized.Go ahead - there we go.And you want to give yourself enough tension to see it, butnot to tear anything. Go ahead. Okay.Let's come down again. Sure.Just push opposite right there - yep. There you go.And just follow that up.Okay, we’ll go in deeper.There we go -from the top, yep.And we’re going to carry this up all the way to the diaphragm -to theesophageal hiatus, basically.Okay and then we'll come back when you've sort of reachedas far as you can go - you go again and then push opposite.Okay.So if you're in thiscorrect plane - which you have to be - thistail of the pancreasis underneath my instrument, and thenthat exposes the adrenal gland, which is on your side.Do you see the adrenal gland yet? No - a little bit maybe.Okay, go ahead. So a fatty wad.I see it - you see it?Yes.I'm glad.Right underneath there. Is this it? Yep. Okay.All right, go ahead - yeah, go ahead, get that.What’s that?Is that the splenic artery? Leave that - that'syeah, that's on my side.You don't want that - you want to be on your side. Yep.Here? Mmhmm.Yep.Yep.Okay.Keep going there.Yep.Is there an NG tube in? Or OG tube? Yes, an OG tube.Yeah, can you suck on it, please? Sure.So as you come around the top,you just want to be careful of the..Diaphragm? And the stomach, which can...Poke its head in? Yep.Because the...So just staycloser to the diaphragm a little bit - yeah,what you can see. So you - yeah,because the stomach's going to be underneath myretractor, and you just don't want topossibly hit it.And now I'm sort of retractingnot only to the patient, you know, tothe patient's right, but also kind of inferiorly bringing it offthe diaphragm - how it comes down - see how it comes down?There's always little bit of fluid up here.And then -So now, we'll keep going. Where's your other instrument? Just?Right here. Okay.You want me to get that little boy? That's fine, yep,So let's go up here and justfinish that. So you see the stomach there?That's why we have to be careful up.And it's gonna -but I sort of try to protect it with thisfan and then -yeah, just get that single layer going up all the way.Yep, just let everything drop down in terms of thestomach, and...Okay, so now let's come back this way.Let's look again, and we're going to get better exposure so,the adrenal gland is right under there. You can see it. It'scovered bynormallayer. Okay so now go opposite of mewith your other instrument -where are you? Just go right in there and justpush a little bit on your side and then you'll open up that planeand keep going, yep.Hold on.Let's make sure we're here - you should be up.Go a little closer,closer up there.So right...Uhh... yeah, right - right in there is fine.Just get that a little bit, yep.Well,there's a plane there, see it there?There we go. Okay.Now this is all now getting - see how it's getting -Now,the key blood vessel I always look for is the phrenic.The phrenic comes down off the diaphragmand runs down here,and the adrenal gland, which is -I'm touching right there - that's the edge of it, you can almost see the edge.And then right under there, running this way is going to be the phrenic.And what you want to do is be right between theadrenal and the phrenic. Okay.So actually I'm going to ask you to take this -hold on one second. Let's do this - a little bit more first, and then gothis way. Then I'm going toshow you because it's a littledifficult to explain. Let’s get a little more exposure here, go ahead.Push a little opposite maybe -just kind of the adrenal. Yep. There you go.Towards you a little more.Yep, okay.Push, push over. Yep, there you go.Okay so what I'm going to ask you to do isis come over here.Okay, so you're going to go in with the -look in with the scope,and you're going to go this way - just carefully because you have thespleen and thepancreas, right? Here is the edge of adrenal.Right? So,I'm going to go like this and just kind of -see the edge?Look, look right in there where my instrument is. You can - no,right there, yeah.So we - so you want to sort of hug thatbecause there's not muchtissue there,but that's going to keep you right on the -the correct side of the phrenic vessel. And once you go like that,and I take my other instrument and pull it over,and now we're going to headnorth,superiorly, and just detach it from theretroperitoneal attachments in the diaphragm.Okay, cool.Now depending if it'scancer you’re operating on,you may do a wider resection in terms of the periadrenal fat -it doesn't hurt to take the periadrenal fat,butyou don't have to for something like abenign aldosteronoma, which is this case, but...So it comes right off the muscle. This plane is almostalways - essentially always - sort of intactunless somebody's had prior surgery or some unusual...So I justmake my way through this fat,and I'm pulling with the other instrument kind of down -so that I know I have the adrenal gland on sort ofmy side.Okay, I'll come this way, so let's now lookagain where we were here over - look over here.So now here's the edge of adrenal.So,but if you follow thephrenic, you’ll always get to it.Look over - look right in here. So we'regoing to stay along this line.Now I usually mobilize the entire adrenalor most of the adrenal beforegetting the vein, but sometimes -it depends on the case. Andif you have a pheochromocytoma especially, and if there's any kind ofhypertension with manipulation...Can I get the suction irrigation?So I often will use a section irrigator -can you clean that for me, please?As my other instrument that way I cankeep itdry of blood and fluid. Let's see - pull back for a second.Can you straighten out the scope, please?Oh yes, it was…

CHAPTER 6

Now your instrument - where's your fan? Right here.You can come closer to me.Unfortunately, I think Igot a little vessel there.Here’s the renal vein which you can see very -and here's the adrenal vein.You can always get around the adrenal veinvery easily. Okie dokie.Almost always.I just want to clean this up and then...Okay, so...There we’re underneath the adrenal, right?Okie dokie.And then hereis the vein,which we can get any time, but I just want to show here -now coming this way.So a lot of times, I’ll dissect out laterally first, so look over here.Here's kidney, and you look for the cleft between the -between the adrenal and thekidney. You have to and then you have to incise here,and you want to find thenatural cleft betweenkidney and adrenal.So there is adrenal gland there.So here is... I think it's right there.Yeah, well the adrenal's over on that side, and the kidney’s here, so you justonce you find that spot you can just go zip zip.Take it right out - see the kidney’s right there?so you hugged the kidneyright there.Once you find it - it's - you can justeasily take this off. And again depending uponthe pathology,you can go out and take more of the periadrenaland even perinephric fat.But here is, again, avascular plane right on the kidney,so it's easy totake this.And then,we're going to get it down to the muscle sowe meet where the dissectionwas above.So again we're just getting theperiadrenal fat, and it's going to come - we did a lotof work from above from the other side, soit's - it becomes very easy togo here and we -get the -sort of connect the dots. Should I bring my fan over there?Let's look down here.So I don’t have much left, right? Because here's the adrenal.Yep.Now sometimes this bit here is a little bit more difficult, but in thiscase it's notthat difficult but you want to getsuperficially - to follow the adrenal -sometimes there's a tongue that goesdown inferiorly more towardsthe kidney, and you have to kind ofmake sure.Do a little bit of the dissection there just to make sure thatwe're below kidney kick -I'm sorry, the capsule of the adrenal - but Ifeel pretty confidentnow that we are,so it's basically going to be all done except the vein.Do we have that 5-mm clip applier?The patient doing okay?Yep.So, we have the adrenal on itspedicle - pretty simple, huh?And then we'll just go like this.Oh, I'm sorry - I'll take the clip applier.Okay, you take the...Take that and clean the...So, we have the adrenal on itspedicle - pretty simple, huh?And then we'll just go like this.Oh, I'm sorry - I'll take the clip applier.

So you load,and then you put it in.Can you look in there?Well hello there.Hi Heather.All right, let’s do the scissors.And then we’ll take a bowel grasper, please.Harmonic.I'll take that bile grasper, please.so I’ll grasp it - not where theactual adrenal is or the tumor. Okay we're going to go like that.And can we have some Trendelenburg and ashift to the patient's left?So we'll just irrigate a little bit.Everything looks...So there's our clip.A little more Trendelenburg and shift to the left, please.And let’s just look at the -come back with the scope now and look -look at the spleen and pancreas kind of.Yep, that's fine.Let's putthe scope in there. We’ll take an Endo Catch bag please.So can you - yeah, you’re straight - right?Where is the - find the adrenal - right there. Adrenal's right here.And you got, this can you come out.Oh yeah, that can come out. That's what...Okay.We'll drop it in.That's good - take that, please.Okay, so looks good, right? So let's look at these trocars and wepull - take them out.Those sites look fine.Okay, and that can come out, and room lights on, please.We can have the Kelly, please.Came out easily because it’s small.Scissors.So we'll take a look at this in a minute, so don't put thatanywhere. Okay.Can I have a wet sponge, please? Left adrenal.And 2 narrow Richardson's,and the Bonnies, and a 0 Vicryl.

CHAPTER 7

So I usually doa stitch above, a stitch below, and thentie the ones together that - that does it -in cases where...It’s slightly larger?Yeah, if we have to enlarge it to take theadrenal gland out, then I’ll often just run this layer.And I’ll just do a figure of 8 just to...Yep, great.Okay, and then let's tie those together, you know, real well.Tie them like across from here? Yeah, yeah, just like that, yep.And I'll take the wet sponge.There's one right there. Okay.More local anesthesia, please.So left adrenal?Yep. Correct.And then post-op for this lady, she gets...So she's going to go home if she's okay.I've been sending... Home?Yep.Depends of course on theunderlying disease. Pheochromocytomas, those patientsdon't go home.Obviously, if somebody has medicalcomorbidities, they don’t go home, but for...Are you guys all set with the local? I'll take some more.For cases like this, if they feel up to it,it's fine.The incisions are basically the same as for a lap chole, so it'sdifferent on the inside, buton the outside it's pretty much the same.And the recovery shouldn't be that much different.Okay.Theoretically, with aldosteronomasof course, they have high blood pressure, andif their blood pressure is a problem at allin the recovery room or earlypost-op, then we would keep them for observation.So this patient,like a lot of patients withaldosteronomas, you don't know for sure -what - you know, how much theirhypertension is going to respond to the surgery.If you fix the aldosterone problem, which I’m sure we did,then her hypokalemia willresolve that problem,andvery likely her - high blood pressure will be a lot better - easier tocontrol and possibly even go awaycompletely, but on the other hand she has otherrisk factors for hypertension.Andthis may notmake her normotensive. That'll be something we’ll have tofigure out over time.I generally have patientstake their blood pressure at homea couple times a day, write it down,so thatwe can have access to that information.The primary care doc can have access to the information.She also has an endocrinologistwho she's been working with in terms of bloodpressure control, so…

CHAPTER 8

You can see - I can -I think see where the tumor is, but we'll see.Yep.I'm just bisecting the gland.So this is - there's actually been somehemorrhage inside this lesion, which is right here.So that's a little bit unusual for an aldosteronoma.I'm not sure what to make of that.But you can see thelesion here.And thenmore normal adrenal.Adrenal. That's more normal-looking adrenal tissue with thecortexthat's yellow on the outside and thebrownmedulla.Here, put the light on it for a second - I’ll show you.So this is the normal adjacent adrenal -see the cortex has a yellowcolor, and then the medulla in the middle - brown.That's normal adrenal. This is the lesion, which you cansee. There's - you know, it’s the roundedlesion, but there’s hemorrhage in the middle. Yeah. Yeah, interesting.That doesn't happen so often without aldosteronomascompared to some other kind of lesions, but...I'm not sure...We’ll wait for the final pathology, yeah.I assume it’s just a benign adenoma.Yeah, so we've finished the closure, just putting Steri-Stripsand little dressings on and thenshe’ll wake up and go to the recovery roomfor a couple hours, andwe'll keep an eye on her for at least 3 or 4 hours today.And if she's okay, she can go home.

CHAPTER 9

So we’ve finished up with the laparoscopic left adrenalectomy.The patient’sbeing woken from anesthesia. Everything went well with the surgery.The only surprising finding, really, was in the beginningwith all the adhesions from thesplenic flexure of the colon up to the abdominal wall.You always see some attachments, but thiswas much more than usual, andI'm not sure if there's been previous inflammation in that area.We didn't see anythingabnormal other than that, but in any case,once we tookthose down, everything else was pretty straightforward andfound that tumor in the adrenal,which we opened up at the end,which did have some hemorrhage in the middle,which I think is a little unusual for aldosteronomas, butI'm not really too concerned about anything like a malignancy in this case.And the expectation is that the patient will have her hypokalemia fixed.The blood pressure response over time - we’ll have to seehow much of her hypertension respondsto the operation. I'm hoping thatshe can go home today - a lot of these patients can - but we'llsee how she does in the recovery roomand for a couple hours afterwards.And she'll, in any case,monitor her blood pressure at home, and I willkeep touch with her closelyto make sure thatshe's on the right medicationsover the next couple weeks as she recovers from the surgery.