Robotic-Assisted Left Adrenalectomy

CHAPTER 1

So this is the set up for the robotic left adrenalectomy where a patient is in the full lateral decubitus position where the left side is up and patient is also flexed in a sense to increase the subcostal space and then the iliac spines to maximize the space for the trocar insertion along the subcostal and the flank. And patient is supported with the armrest, as well as the beanbag supporting her body. And patient is slightly tilted to the left to again expose the abdominal space.

So on the left side, your camera trocar is slightly higher than the right side, 'cause on the left side, you have to mobilize the spleen all the way up to the diaphragm. to the left crus, right? Yeah. You have a longer... Yeah. So generally, so for the right side I go lateral to the umbilicus here. I go about, you know, an inch or two inches above the umbilicus. Okay. So, making an incision, let's say... So pretty good height there. So adrenal gland is gonna be back here mobilizing the spleen to the stomach. So the idea is to not compromise the triangulation. So one trocar will go around here. You just put in midline here? Yeah, in between. Yeah, this one. I mean in between these two? Right. And then the camera. This may change once you insufflate the patient. Yeah. Okay. And then the third one. You do your Veress? Yeah, let's see. This is okay. So once the patient's insufflated, it may shift everything a little bit kind of more lateral. I see. So I'll do this dotted line here. Right? Okay. And dotted line here. Okay. Then put one more here. Like so. So having a good triangulation of the instruments, right? Going towards the adrenal gland, which is the target. We're gonna be around there. Okay. All right. And then assistant trocar if you need it, we can put one in here just for the retraction or suction/irrigation. Sure. Those are 8-mm trocars, right? So this, I like to actually intentionally put it through the rectus sheath for a good posterior and anterior fascia closure. Oh, so you don't have to close... Well, but in a small, you know, aldosteronoma case like this, you may not necessarily have to do a closure other than using an endoclosure device. Okay. So it doesn't, you know, matter as much. So I think, you know, doing it here, in here to give that space, maximum space. Timeout. We're here for the left robotic adrenalectomy, possible open. Patient is marked on the left side. Prep is dry and patient is placed in a full lateral decubitus position with the left side up and flexed position. Patient has been supported with the beanbag paddings as well as exterior roll arm pad. And then the legs are supported as well. Okay. Anticipated time of surgery should be about an hour to an hour and a half operation. Okay. Patient has a Foley catheter, and patient has a OG tube in? Okay. Yeah, her blood pressure has been well controlled on Aldactone and Norvasc for her aldosteronoma. Okay.

CHAPTER 2

All right. Patient has stomach decompressed right, and paralyzed. Okay. So, okay. 11 blade. So let's - what it meant - intercostal. Palmer's. Yeah, here we go. Okay. Okay, incision. A little more. Okay, good. Okay. Veress needle. You do it with a syringe or without? Oh, without. And we'll put it in. Okay. So I like to kind of generally angle, you know, under the subcostal space so that the ribcage actually can act as a little tent so that it actually tents up the abdominal wall fascia. So you can actually feel the... So towards myself. Yeah, exactly. Like this. Good. And don't let go of the pressure and keep going in. Feel those pop. Okay, keep going. Something's still there. Okay. I'm in. May be in. All right. Aspirate Nothing. All right, very nice. Okay. Gas, please. Gas on, please. So we're using the Veress needle entry to get into the abdomen. Given that this is a left-sided adrenalectomy with the patient's full lateral decubitus position, it allows to use a Veress needle to get in and the initial pressure is low. And then with a good flow, the flow is limited by the actual diameter of the Veress needle at this point Then use an Optiview. We're gonna use Optiview to get in here. Okay. Put one here. One here. Okay. And then let's put the assistance. Sure. Okay? Trocar in there. Five-millimeter assistant for the left side, and for the right side to retract the liver, I usually do... Is it 10 point? Yeah, 10-12-millimeter - yeah, trocar. All right. I think we're up to the pressure. Okay. Just come on out. Oh, you don't leave it? No, I don't. Okay. I feel like there's no point of leaving it in. Okay. Okay. You can turn the gas off, please. Yep.

Okay, knife down. Do you wanna clean these up first? I think that will stop in the skin with the trocar. Okay. Take the Optiview. Okay. Make sure that you're focused. Better? There we go. All right. Rectus, posterior. Okay, going through the anterior posterior fascia there. Right? You're in. And we're in. Okay. Okay, let's take the obturator out and let's confirm that we're inside and we are. Okay. I think we can come back out a little bit. Okay. Gas back on, please. Want 30 degree or? Yeah, 30 degree, please. Regular scope. Can you get the room light down please? Going down. We're in. Good, okay. Sounds good. Okay, so you have the ascending colon there. All right? Okay. A little bit of the omentum adhesions. You can take that down. Omentum, spleen, liver. Okay. Stomach's gonna be underneath this omentum there. Okay. All right.

We'll take the local. So this is the more proximal port? Yeah, that's more proximal. You wanna do the... The more lateral. Yeah, I think there's plenty of space here. Okay. Okay. This will be... I think it can go slightly higher, actually. Higher as well. Yeah. Okay. Cause there's more space. Fill the rib border there now. Okay, good. This will be the robotic trocar. 11 blade. Sorry. Go back. Oh, 15. Eight millimeter. Make it small, eight millimeter. Okay? Oh, okay. All right. Try to aim towards the back towards the adrenal. So like that? Yep. Okay. That's good. Okay, now hold the camera for me now. Another eight-millimeter robotic trocar, please. Knife down Local, please. Can you have a Ray-Tec?

Needle down. 11. Five-millimeter trocar. Knife down. Okay, all right. We're ready for the robot. The camera and a warmer, please.

CHAPTER 3

And then you... Turn to your right a little bit now. Start turning to the left now. Good. Okay, stop. Go back slightly. All right. Keep coming in. Your arm okay there? Yeah. Come a little more. Stop, all right. So here's. Then after the robot arm's docked, try to burp it, meaning that, kind of burp it out of the abdomen instead of making an impression into it. Yeah, but this one, I'm gonna bend out. Okay, sounds good. Because yours, right. Let me get this camera in there first. Okay. Just to lift the abdomen up top, okay. Exactly right. To give that extra space. So it's nice here. It's not, one, it's not pressing into the abdomen or causing any stress to the abdominal wall. Sure. Where the fulcrum of the robotic trocar or even the camera trocar's right at the abdominal wall, so there doesn't cause much of a stress on the abdominal wall. Okay. Two on one. Yeah, I think this is better out. Yeah? Yeah. Very nice. So this is the double fenestrated grasper, which has the longest jaw, but also it's one of the softest or gentlest grasper that you can use to grasp bowel. And the length of the grasper gives the advantage of retracting the organs, such as the spleen or liver. So again, the whole point of this setup here is to provide a ideal triangulation with the camera in the middle and then two instruments here. One can be used for an energy device or a grasper. And then you can have an assistant trocar on the side for any retractions. Okay, camera please. Yeah, double fenestrated grasper. Actually let's do this here. Harmonic. Okay. Okay, all right. Docking is done.

CHAPTER 4

This is the spleen here, and this is the left lobe of the liver. And stomach's gonna be underneath here. Okay. And this is a omentum fat with some adhesions that we're gonna take down. And for the left adrenalectomy, I'll be mobilizing the splenic flexure of the colon by taking several of the attachments. Can you just open up the vent for suction, please? Sure.

This thin layer of peritoneum will be divided preserving the supplied - the mesocolon to the splenic flexure. And this will help to mobilize the splenic flexure to expose the retroperitoneum. Okay, all right. Okay. And can you switch the Harmonic and the double fenestrated grasper, please. Sure. Okay. Thank you.

Angely, can you move up the entire camera arm so that I'm looking down a little more? Thank you. Mm-hmm. Did that help at all? I don't know. A little bit. No, I think it moved a little bit. It's just a little, it's not so much give on her belly. You want me to try to move it up more? No, I think it's the - I think I've reached the maximum angle or zoom. Yeah. So one of the landmarks for the left adrenalectomy is the inferior phrenic vein. Right? Mm-hmm. So I need to mobilize the spleen and the pancreas to expose the inferior phrenic vein on the left side. And that will tell me that once I follow the vein down, that's where the adrenal vein and then... Should be. And the renal vein. Yeah, it should be, right?

Now let's see. So patient has a lot of omental fat here, right? So this all needs to be kind of moved out of our surgical view. These in there. Okay, take. Okay. This is the tissue plane mobilizing the distal transfers and the splenic flexure here now to expose the retroperitoneum. Angely, how are the arms on the outside? They're fine. They're clear on your side, right, Vincent? Yeah. It's okay on my side. Yeah. They're fine. Thank you. I mean, you're all pretty high up. Nothing's down near the patient. Okay. Let me know if there's any concern for arm fighting. So Angely, do you see what this is here? Pancreas. Yeah, that's the pancreas. So this is a tissue plane here. We're gonna try to divide and then mobilize the entire pancreas and spleen medially. So that's a very avascular plane. All right, Angely, can you come in with a bowel grasper? Sure. Now, and then try to retract the spleen and the pancreas? Okay, very nice. Yes, you can come underneath here and then retract - yeah, the entire... Nice, yes, that's it. Okay, let's go backwards a little bit here now. And then let's see if I can mobilize this colon a little bit more. Colon. Simple traction, counter traction. Okay, put your instrument right in here. Yes, yep. Okay, and then we started making our way up back towards the spleen. Okay. Bleeding here. Start back here again. There's a vein. Yeah. Okay. We'll define what that vein is. Let's go way up here now. Let's try to free up the spleen. That's part of the stomach there, right? Yeah. Okay. So we have a good mobilization of the spleen. Okay, and once you have the mobilization, full mobilization of the spleen like this, gravity should help with the retraction. Mm-hmm. Okay, that's good. You want this? Okay.

Push down here. Yes, right in there. All right, let's see. So this vein here... This is still the pancreas here. Mm-hmm. Okay, let's mobilize the pancreas a little more. I'm pulling. Yeah. So retract medially here, please. Preserving the splenic vessels. Keep it down and yeah, all the way down. Good. Now that's probably the phrenic vein coming down, that vein on the retroperitoneum. So let's mobilize a little more on top of the phrenic vein. Mm-hmm. So here's a funny vein coming down, right? Mm-hmm. Stomach. Okay, I think that's a good mobilization here. Now the adrenal tumor may be in this mess here. So now let the spleen, stomach, and then the pancreas all be retracted down from the gravity. And continuing the open book technique here. And following the inferior phrenic vein down here. Okay. So if you see that little golden right there, that's the adrenal - that's the adrenal gland and the tumor embedded in the adrenal gland there. Come in and recheck here, please. Just down? Recheck down. Medially? Right down here. I'm gonna try to go under your... Yeah. Okay. Thanks. Great. Put in a little more deeper in that area there. Good. Instead of, yeah. And then push it down this way. Exactly. Kind of thin out the retroperitoneum layer by layer. Now that's the actual psoas muscle there, right? So now we're in the most posterior layer of the retroperitoneum. Okay, so what I'm gonna do from now - here. Hold on a little more You want me to hold the colon down or are you okay? Yeah, I can sort of pull the colon down just a little more. Yeah, push it down for us. Sweep it down. Grab it here, and then just pull it up. Good, that's it. Keep it steady. You just keep it steady. Okay.

CHAPTER 5

Now, that looks like a kidney. And then the border between the kidney and the adrenal gland and the tumor is probably somewhere around here. So what I try to do is I try to, thin out the peritoneum on top of the kidney to define the border of the kidney. Okay, here is the kidney, right? Yep. So once I get into the Gerota's fascia. Then I shave off the perinephric fat to keep a clean margin on the adrenal tissue. Come back there. Blood pressure where you need to try to get to the vein as soon as possible. There's no urgency in terms of trying to get the adrenal vein exposed and divided. So here I'm mobilizing the adrenal gland medially and laterally before dissecting the adrenal vein and then the renal vein. Bring in a suction/irrigation. Oh, suction? Yeah, suction/irrigation. Okay, hold on. Hold on, not there. So between the hilum of the kidney here that you can see. Uh-huh. And then knowing where the adrenal tumor is here. Again, that golden brown. Yeah. That tumor right there. The normal adrenal tongue tissue, there'd be a medial, as well as the inferior tongue coming down. So I'm demarcating the landmarks before dissecting down to your adrenal vein. Can we do a little suction/irrigation, please? Okay. Okay, good. All right. Check the fat down this way.

Okay, good. So use that for retraction. Good. I'm gonna thin out this fat here. Hold on. Now there's a structure that looks like a vein exposed now, right? Yeah. Right there. You see it? Yeah. So that's the adrenal vein here, and then the renal vein going across here. Okay, I'm gonna clean up. Just steady. Okay, so here's the renal vein. Do a little irrigation, please. Good. Suction. All right. So I'm isolating the vein. Uh-huh. Now provide that traction there that you were doing. Good. So that's the adrenal vein. Take it high up. Okay.

Okay, suction in here, up here. All right, Angely, provide a counter traction there. Good. So here's the psoas muscle. No need for retraction there. Okay, now, so you can see that the tumor is well included in our specimen here. Now let's go back here. Suction/irrigation. Something here. Now from here, our goal is to connect the dots from the mobilization we did here along the renal hilum, knowing that where the renal vein is. Let it thin out. Okay, irrigation. Suction. Suction and counter traction. Irrigation. All right, that's good. This is part of the adrenal gland here. Okay, provide retraction here for me. Okay, relax. I am cradling the adrenal gland and the tumor in my left hand, and then detaching it from the perinephric fat. Okay, all right. Okay, suction/irrigation.

CHAPTER 6

So here's our - be careful, that's your adrenal vein. So here's your adrenal vein. Angely focus here. Retract down here and suction down here. Good. So that's her adrenal vein that's been divided using - adrenal vein divided using the Harmonic scalpel. And then here's the renal vein going across. Okay. Depending on the length or the size of the vein, I may put a clip applier or just use a Harmonic scalpel, given that it's a low pressure system. Okay, all right. And here's your psoas muscle. Okay.

CHAPTER 7

Okay. Let's take the instruments out. We're done. We'll use the eight-millimeter camera. Okay, extract the specimen and close the fascia. Do we have the endoclosure device? Right here. Okay. I need a new top glove, please. Six and a half white. Okay. All right, this is... It's coming out, that's why. Do you have the introducer? I think you're right there, hold on. Hold on. Yeah, just push through. Okay. Yeah. Good. All right. Want the room lights down a little? Yeah, room lights down, please. Can I have a grasper, please? Have one here. Open up the bag first. Push it through and then... Oh, how do we get this back? Just close it on there. Push this way? I don't know. Yeah, just push it, open up. Nice. Okay, good. All right. Put the specimen in there. Just that. Yeah, don't grab it. Don't grab the tumor. Yes, ma'am. Okay, I got it. Relax. I wanna push it in more, or are you gonna come towards me? Sure, okay. Okay, good. All right. Okay. That's good, all right. We'll use an endoclosure device with a 0 Vicryl suture. Get one of the room lights, please? All right. Let me get 11 blade first. Okay, knife down. And I'll take a Kelly. Okay. Let me see, relax. Okay. Okay, Kelly. Okay, pull this please. Pull a little less. Okay. That should be enough. I think so. Let's see. Almost, not quite. Let's not struggle. Okay, go back in. It's posterior. Let's get the anterior a little more. Hold on. Now let's get the posterior a little bit there. Now the S-retractor. You're good. Okay. Just give it a spread. Okay, that's our specimen. And there's the tumor. Yeah. You cut it on the back table, right? This one we'll cut it out on the back table. In fact, yeah. We'll open the tumor. Okay.

CHAPTER 8

Camera back, please. Eight millimeter. No, I think we can just close, you know, open? Yeah. Yeah. Okay. All right. Can we actually get a UR-6 suture? Do you have it? Yeah, yeah. Okay, all right. Let's do that. Camera back. All right, let's have our gas off. Yeah, lights on. It's just a figure-of-eight? She's so skinny. Yeah. Okay, S-retractors, Ray Tec. Middle down. Let's get those bleeding. You can see. Get the Bovie. Can I have an Adson some with teeth, please? Can I have a second one? I'll evert the skin edges for you. Yeah, I got this. It's coming from... Below. This, yeah. I'll expose for you. It's here, huh? Okay. Try that. It is like at 12 o'clock. Yeah. All right. This one's okay. It'll stop. I think that's okay. All right, okay. All right, I'll take the UR-6, The two S-retractors I have, I'll give you the Adsons back. Figure-of-eight, maybe? Yeah, figure-of-eight. Okay. I'll show you the top first. Okay. This muscle. Muscle. Show me the fascia of this muscle. A little here. There you go. Okay. I won't move until... Sounds good. You got it? Still your side. There you go. There's fascia. I think just one figure-of-eight should be fine. I think so. Okay. Okay. There you go. You see it? Mm-hmm. Okay. I think I will do one more. One more, yeah. Interrupted. One more figure-of-eight. Towards me or towards you? Towards me. I'll leave this. Do you want me to use it to pull up the fascia? Yeah, can cut there. Just an interrupted. Yeah, one interrupted towards me. No, you gonna get it from outside. Oh Yeah. This is down. Yes, yep. There we go. This suture's not that long. Scissors. Can you cut this for me? You have another pick up? Another pick up? Yep. Here, let me see. I just want this out of my stitch. Yeah, you can kind of, yeah. I'll do two. You do these the same? Interrupted and Dermabond? Interrupted. Yeah. Oh, okay. Scissors right here. Thanks. Do you let them eat post-op or clears? Hmm? Do you let them eat post-op, or do you put them on clears? Yeah, they can eat. Yeah, they can eat. Okay. And just stay overnight for. Yes, yeah. Check the electrolytes in the morning. Okay. Yeah, continue the Norvasc, take her off the Aldactone. Okay. We stretch that a little bit on the skin. I have a lap pad. I have a lap pad, too. If you wanna remove the lap pads, you can. You still have a little bit of a moist. Okay. Okay, do you have the Dermabond? Just rub on her Veress site. This one is the one that's a little stretched out. Felt a little tight, yeah. Two layers. Okay, that's it. Good. Thank you.

CHAPTER 9

So that was the robotic-assisted laparoscopic left adrenalectomy for the hyperaldosteronism. And patient had at 1.5-centimeter left aldosterone-producing adenoma. And she was well controlled with her medications preoperatively, and throughout the surgery, patient did very well without any fluctuation of her blood pressure. And patient at this point will be admitted postoperatively for observation. And we'll be sending out labs in the morning and she'll be discharged tomorrow. Okay. So I'm opening up the specimen and bi-valving the adenoma to examine the tumor. So it looks like a pretty classical aldosteronoma, where adrenal adenoma has this golden tan color with a surrounding normal adrenal gland tissue, as well as the fats surrounding the adrenal gland. So it's a well-circumscribed adenoma. And these are almost always benign. In terms of the hyperaldosteronism, successfully removing the aldosteronoma cures the patients of a refractory hypertension, where patient's blood pressures were driven by the hyperaldosteronism secondary to the adenoma.