Bilateral Posterior Retroperitoneoscopic Adrenalectomy with Cortical Sparing on Right Side

CHAPTER 1

I am Tobias Carling, I'm doing a bilateral retroperitoneoscopic posterior adrenalectomy. This is a patient that has pheochromocytoma bilaterally in the setting of MEN-2. Posterior retroperitoneoscopic adrenalectomy, we've been doing close to 10 years, here at Yale now, and we're one of the major centers in the world for this operation. The major advantage of doing a posterior retroperitoneoscopic adrenalectomy especially in the bilateral setting, is that it's much faster, quicker recovery, and the patients are faster back to normal activities. So, this patient is a 31-year-old female who was recently diagnosed with bilateral pheochromocytoma in the setting of MEN-2. As part of her workup, she also was diagnosed to have medullary thyroid cancer, which we'll be addressing in a couple of weeks. But because of her biochemically unequivocal pheochromocytoma syndrome, we elected to do the adrenalectomy first, so she has been on preoperative alpha blockade, and hemodynamically she's now ready for surgery. Studying her CAT Scan, as you can see here, is very important in this particular case because we want to try to achieve a cortical-sparing approach. And as you can see on the right side, you have the liver here and then you have the adrenal tumor on the right side here and on the left side - the aorta, the vena cava, and then the left kidney and the right kidney. And if you study very carefully this CT scan, you can see that almost a 5-cm pheochromocytoma on the right side and about 6-cm on the left side. But sitting right next to the vena cava, you actually have a little sliver of normal adrenal tissue, normal adrenal cortex, and that's why we will attempt to do a cortical-sparing resection on the right side. On the left side, however, pretty much the entire adrenal gland is replaced by this big, 6-cm pheochromocytoma. So a cortical-sparing resection is not possible on the left side. So that's why we started on the right side. So we started the operation on the right side doing a right posterior retroperitoneoscopic adrenalectomy. The ports are placed under direct palpation. We then identified the kidney. We do a fair amount of the dissection on the kidney without even seeing the tumor. But as the tumor is relatively large, you can easily see the tumor, which is sort of pale/gray compared to the normal adrenal cortex, which is more yellowish. And as you can see in the dissection, key landmarks on the right side is to identify the superior pole of the kidney, as well as the vena cava, and then in this particular case, the adrenal vein was sort of tucked underneath at the actual tumor, so that was ligated towards the very end of the operation. But as you could see, inferiorly and anteriorly there was a sliver of normal adrenal cortex as we predicted based on the CT scan. And this was able to be preserved, such that hopefully she'll have some cortisol production. We'll obviously measure that very carefully postoperatively to see whether she will need replacement or not. But once then the IVC as well as the kidney and behind the retroperitoneum, the liver had been identified, the dissection was quite straight forward and was done pretty much just with the LigaSure. So we then proceeded to the left side, which is done in a very similar fashion. The landmarks, again, is the superior pole of the kidney. As you can see, there was some superficial veins that we ligated with clips, but then the left adrenal vein as well as the phrenic vein, was easily identified and ligated as well, and again, the rest of the dissection was quite straight forward using just the LigaSure to divide all small, adrenal arteries to the left adrenal gland. The closure is relatively straight forward. The closure on the fascia for the big port, and then just a subcuticular closure for the skin.

CHAPTER 2

All right, so we're doing a bilateral adrenalectomy in a patient with MEN-2 that have bilateral pheochromocytoma, so we're going to attempt to do a cortical-sparing operation. The patient is 31 years old and was just recently diagnosed with both bilateral pheochromocytomas as well as medullary thyroid cancer.

CHAPTER 3

Okay. That's good. So I do a fair amount of the dissection here just bluntly, because I can sort of feel the tip of the kidney, right there. Okay.

Okay, that feels good. All right, we'll take the gas on.

Okay. Yep. All right, I'll take a LigaSure.

CHAPTER 4

Okay. Just show me muscle here. Okay, so that's the para - whoa, whoa, whoa, okay. Let's… I'll take a bowel grasper.

All right, so we got the kidney here. So, I'm just going to start mobilizing the superior pole of the kidney here. Can you just step down like… So we're mobilizing the superior pole of the kidney- so we do a fair amount of the operation without even seeing the adrenal at first. Okay. Okay. Okay. Come out and clean.

CHAPTER 5

Okay. All right, so come in here a little bit. So here is the pheochromocytoma, so I'm going to make sure I stay right on the peritoneal side here, because we want to see if we can save some cortex on this side, so - come back a little bit. That's adrenal cortex right there, which seems to be unaffected by the pheochromocytoma. It seems like the pheo ends right here. So if we could save this piece of normal adrenal cortex, that would be good. We're just going to mobilize a little bit more. Yeah. So I have the vena cava here, so - the vein is going to come in somewhere here, but because we want to save this piece of adrenal, we're going to eventually come across somewhere around here. But let's take a look. Over here, so come back now. And then, stay up here. Okay. Come back here. Okay, all right. Okay, so come back a little bit. Let's take a look. Can I have a suction for a second.

All right, so, I think - it feels like the tumor ends right here. So we're leaving this piece of adrenal tissue. Come back a little bit. Let's see… All right. Okay, come back a little bit. Cut - you're fighting me. So he's bleeding a little bit because we're coming through the adrenal parenchyma here. So I'm lifting the adrenal off the IVC here, so I'm taking care not to grab the actual pheochromocytoma or the - or the adrenal gland, but rather the fat next to it. Okay, that's good.

Now I'm going to grab that as high up as I can. And anesthesia, you guys are doing fine, right? Yeah. Because we're almost done with the left side here, so - right side, sorry. Okay, can you slide past that kidney at all? Just take a few steps down. Okay, so let's see what we got. So just come back a little bit. I'm just going to view it from below here. Okay. So that's normal adrenal there, and then, we got… I think that's the actual vein there. Okay. So we're going to ligate the vein here. You know, so the pheo is going right to the vein there, so we're not going to be able to leave any more adrenal cortex. So we have normal adrenal cortex here, just show that for a second. That looks, you know, very healthy. So, we're going to need a clip applier now.

So, her pressure might drop even a little bit lower now because we're ligating the right adrenal vein here. Uh, give me a… A LigaSure. All right, so come back and show me it. All right, are you happy with that? Do we want to put another clip on? Okay. Okay. Okay, good. All right, so we'll take a - Endo Catch.

CHAPTER 6

Okay. All right. All right, so we'll take lights on and gas off, all that stuff. All right, let's take a feel there, see if you can get it out. You might have to open it up a little bit. Okay. All right, so right adrenal. So call this right adrenal, cortical sparing. And then we'll take the ports back. I'm going to take another look.

CHAPTER 7

Okay, so that's the IVC, and then - so here's that - that's the right adrenal vein, right there. We were able to preserve some normal adrenal cortex, right here. And then the IVC looks good - no bleeding, no nothing. Okay.

CHAPTER 8

[No Dialogue.]

CHAPTER 9

All right, so we're going to start doing the left side. So again, doing a fair amount of dissection bluntly here, feeling for the paraspinous muscle.

And then I'll sort of angle this about 30 degrees up towards the adrenal, which will be up here. A port.

Okay. I'll take the camera. Gas on. Okay. All right, I'll take the LigaSure.

CHAPTER 10

Okay. So the first order of business is just to find your instruments and start creating the retroperitoneal space here.

So I've got the kidney here. Thank you. So, come back a little bit. Look down here. Thank you. Okay.

CHAPTER 11

All right, so we mobilized the kidney here. The tumor is sitting right up here. And the left adrenal vein is going to be down in this area. We'll get to it pretty soon. Okay. All right, so show me over here now. All right, so… Yep. So, I think that's the tip of it, come back a little bit. I just want to bring this even a little bit more like so. Okay. All right, come back a little bit. I don't love the exposure just yet. So the pancreatic tail is going to be right back here. That's a little bit of normal adrenal cortex there. Okay, come back. Come back a little bit. Okay. All right, come back. All right, just open this up a little bit more, so I can flip the kidney. Okay. Okay. These are the corners. They were underneath it right here. All right, just clean it for a second. When I was looking at the scan, and there's like pretty much tumor all the way to the vein here, so that's why the right was better to… To do the cortical sparing on. That's going to be the adrenal vein, right here. We're going to need a clip in the second. Thank you. All right, anesthesia, so we're ready to ligate the left adrenal vein here, so- so you might drop the pressure a little bit. Hopefully, not too much. All right, so, okay. Yeah. Okay, I'll take the clip. Okay. And I'm grabbing the adrenal vein with my grasper, which is a good place to grab because then I can mobilize the whole… Are we off the clip there - okay. All right. There might be another… No, I think that's just… Yeah, so this is the real vein, and also the phrenic vein is heading up right there. Yeah, so just follow me up here. Okay, so I can come back down. All right, so we'll take a clip again.

So we're - the previous one was just a superficial vein. This is the main adrenal vein we're clipping right now, so, just so you know. So here is obviously the kidney, here is the tumor, this is the left adrenal vein, that's the phrenic vein heading out there, so we're ligating it on the adrenal side of that. Okay, good. All right, so come back now. Now we're going to grab it as high as possible.

It's here. All right, good. Okay.

CHAPTER 12

All right, lights on. So the tumor is almost 5 cm, so we need to open up a little bit more. Thank you, Sam. That's good. Yep. Can I have a Kelly? There we go. All right, beautiful. So a little bit of normal cortex, but a typical pheochromocytoma.

CHAPTER 13

[No Dialogue.]

CHAPTER 14

So we just completed the bilateral posterior retroperitoneoscopic adrenalectomy. As you could see, the operation went really well, really no blood loss or any major difficulties. As you could see, we were able to save a small piece of normal adrenal cortex on the right side. Obviously, the key when you do a cortical-sparing adrenalectomy in the setting of MEN-2A is that you want to leave enough adrenal cortex such that the patient has cortisol production. But you don't want to leave too much or risk spilling pheochromocytoma tumor cells because then the patient can have a recurrence in the adrenal bed. So I think we were able to achieve that, where we just left a small piece of adrenal cortex on the IVC. The reason we did it on the right side as opposed to the left side is because we could predict based on the CT scan that it wouldn't be possible to save normal adrenal cortex on the left side because of the size of the tumor and the tumor encompassing the entire left adrenal gland. The patient did very well, hemodynamically, did not have any major swings in blood pressure and heart rate during the operation. And we always have a multidisciplinary pheochromocytoma team when we do this operation, with anesthesiologists that are used to this operation because there can be some challenges keeping up with the swings in the blood pressure primarily, but that was not a major issue in this particular case. Both sides went quite straightforward, and because of it being a pheochromocytoma, we'll routinely keep the patient in the ICU. I don't anticipate any issues in the blood pressure going forward, but that's a major reason to keep them in the ICU. If she does fabulously well, she may be able to go home tomorrow. If she needs to spend one more night in the hospital, that's fine as well. So postoperatively, as I mentioned, the patient will probably go home tomorrow or the next day. She'll have some soreness, because with the ports, as you can see, we do split some of the retroperitoneal muscles, so she'll have some soreness from that. A key obviously will be to measure her cortisol production, so we'll do what's called a cosyntropin stimulation test tomorrow morning to see if she has cortisol production. She may need a period of time of supplemental Prednisone, but that will be dependent on the lab tests tomorrow. Otherwise, people recover quite rapidly from this operation. Most people are back to normal activities in 1 to 2 weeks, and going forward, obviously, because of her MEN-2, she'll be surveilled the rest of her life, both for recurrence of pheochromocytoma, but also, as I mentioned, she also has a medullary thyroid cancer that I will operate on in a few weeks once she's, recovered from this operation.