Left Laparoscopic Transperitoneal Adrenalectomy for Aldosteronoma

CHAPTER 1

Hi. My name is Richard Hodin. I'm a surgeon at Massachusetts General Hospital and chief of our endocrine surgery unit. We're going to be doing a laparoscopic left adrenalectomy today for a patient with an aldosteronoma. This is a 48-year-old woman who has long-standing hypertension, has been on multiple medications, and was also noted to have hypokalemia, and eventually was sent to an endocrinologist who did the appropriate blood test and biochemically confirm that she had hyperaldosteronism with a suppressed renin level and and was therefore diagnosed with aldosteronism. And then she had a CAT scan. The CAT scan showed a normal right adrenal gland and a sort of the lobulated left adrenal gland with just a very small - what appeared to be an 8-mm nodule - not a huge mass but consistent with a small lesion that we often see with aldosteronomas. She went on to have adrenal vein sampling done, and this confirmed the step up on the left side with a very high all aldosterone level compared to the control cortisol, compared to the right side, so the ratio is quite high - over three - and therefore that confirmed that this was almost certainly a left-sided aldosteronoma. And we are going to remove the adrenal gland today, again, with a laparoscopic left adrenalectomy. So this is the CAT scan, and it shows as we come down, a small adrenal nodule - not huge but clearly 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 the adrenal vein sampling, we’re confident that this patient should have her left adrenal gland removed.

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

I do a left paramedian open laparoscopic technique, so through the left paramedian position, we’ll place the Hasson trocar and then obtain a pneumoperitoneum, and then we will place an 11-mm trocar in the epigastrium and two 5-mm trocars along the left costal margin or a little below that. And then we will mobilize things - mobilize the colon inferomedially - the spleen and tail of the pancreas to the patient's right and then circumferentially dissect the adrenal gland away from all of his attachments and find the adrenal vein, which we will clip. And then the gland will be removed, 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 the abdomen, chest, and back region just in case we have to make a open incision, and even theoretically, although I'm sure it won't happen, 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 go in a paramedian spot - so we’ll be above the umbilicus, but just it helps with visualization.

So here is the ribs, and what we're going to do is a paramedian, usually up a little bit superior to the umbilicus. If there's kind of - if there's a panis, I usually let it drop down and go a 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 preemptive analgesia, right? Which apparently works better than if you do it at the end. We do it at the end also, but I do it before. So we'll take the Bovie and sponge. So just use cut and make 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 two Richardson'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 a forceps 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 the anterior 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 want to 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 the pressure up - set it at 17 - 1. Looking in, we've got some adhesions - some sort of extra attachments of the omentum up here, unfortunately. So we’ll have to take those down. We'll come in with our epigastric 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 here in 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 now is put in the other two trocars - at least the lateral one first, so looking up towards the left upper quadrant. The colon - we obviously stay away from that - why don't you bring 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 be about here, halfway between the paramedian and the latter one. Okay, I'll take the fan retractor, just hold the scope for one minute, please.

CHAPTER 4

So let's now continue by - that's fine - taking down the colon - 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 to vent 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 - just right there - just to give us a little more mobility, but then the key thing is next - is to get between the colon 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 pressing on. So I open up this - let's get that bleeder 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 the kidney 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 and we 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

So we'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 come there, and you push the other direction, and it opens it right 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's underneath 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 this to 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, but not 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 the esophageal hiatus, basically. Okay and then we'll come back when you've sort of reached as far as you can go - you go again and then push opposite. Okay. So if you're in this correct plane - which you have to be - this tail of the pancreas is underneath my instrument, and then that 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's yeah, 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 stay closer to the diaphragm a little bit - yeah, what you can see. So you - yeah, because the stomach's going to be underneath my retractor, and you just don't want to possibly hit it. And now I'm sort of retracting not only to the patient, you know, to the patient's right, but also kind of inferiorly bringing it off the 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 just finish 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 this fan and then - yeah, just get that single layer going up all the way. Yep, just let everything drop down in terms of the stomach, 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's covered by normal layer. Okay so now go opposite of me with your other instrument - where are you? Just go right in there and just push a little bit on your side and then you'll open up that plane and 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 diaphragm and 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 the adrenal 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 go this way. Then I'm going to show you because it's a little difficult 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 is is 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 the spleen and the pancreas, 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 that because there's not much tissue 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 head north, superiorly, and just detach it from the retroperitoneal attachments in the diaphragm. Okay, cool. Now depending if it's cancer 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, but you don't have to for something like a benign aldosteronoma, which is this case, but... So it comes right off the muscle. This plane is almost always - essentially always - sort of intact unless somebody's had prior surgery or some unusual... So I just make 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 of my side. Okay, I'll come this way, so let's now look again where we were here over - look over here. So now here's the edge of adrenal. So, but if you follow the phrenic, you’ll always get to it. Look over - look right in here. So we're going to stay along this line. Now I usually mobilize the entire adrenal or most of the adrenal before getting the vein, but sometimes - it depends on the case. And if you have a pheochromocytoma especially, and if there's any kind of hypertension 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 can keep it dry 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 I got 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 vein very 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 here is 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 the kidney. You have to and then you have to incise here, and you want to find the natural cleft between kidney 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 just once you find that spot you can just go zip zip. Take it right out - see the kidney’s right there? so you hugged the kidney right there. Once you find it - it's - you can just easily take this off. And again depending upon the pathology, you can go out and take more of the periadrenal and even perinephric fat. But here is, again, avascular plane right on the kidney, so it's easy to take this. And then, we're going to get it down to the muscle so we meet where the dissection was above. So again we're just getting the periadrenal fat, and it's going to come - we did a lot of work from above from the other side, so it's - it becomes very easy to go 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 this case it's not that difficult but you want to get superficially - to follow the adrenal - sometimes there's a tongue that goes down inferiorly more towards the kidney, and you have to kind of make sure. Do a little bit of the dissection there just to make sure that we're below kidney kick - I'm sorry, the capsule of the adrenal - but I feel pretty confident now 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 its pedicle - 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 its pedicle - 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 the actual adrenal is or the tumor. Okay we're going to go like that. And can we have some Trendelenburg and a shift 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 put the 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 we pull - 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 that anywhere. 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 do a stitch above, a stitch below, and then tie the ones together that - that does it - in cases where... It’s slightly larger? Yeah, if we have to enlarge it to take the adrenal 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 the underlying disease. Pheochromocytomas, those patients don't go home. Obviously, if somebody has medical comorbidities, 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's different on the inside, but on the outside it's pretty much the same. And the recovery shouldn't be that much different. Okay. Theoretically, with aldosteronomas of course, they have high blood pressure, and if their blood pressure is a problem at all in the recovery room or early post-op, then we would keep them for observation. So this patient, like a lot of patients with aldosteronomas, you don't know for sure - what - you know, how much their hypertension is going to respond to the surgery. If you fix the aldosterone problem, which I’m sure we did, then her hypokalemia will resolve that problem, and very likely her - high blood pressure will be a lot better - easier to control and possibly even go away completely, but on the other hand she has other risk factors for hypertension. And this may not make her normotensive. That'll be something we’ll have to figure out over time. I generally have patients take their blood pressure at home a couple times a day, write it down, so that we can have access to that information. The primary care doc can have access to the information. She also has an endocrinologist who she's been working with in terms of blood pressure 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 some hemorrhage 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 the lesion here. And then more normal adrenal. Adrenal. That's more normal-looking adrenal tissue with the cortex that's yellow on the outside and the brown medulla. 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 yellow color, and then the medulla in the middle - brown. That's normal adrenal. This is the lesion, which you can see. There's - you know, it’s the rounded lesion, but there’s hemorrhage in the middle. Yeah. Yeah, interesting. That doesn't happen so often without aldosteronomas compared 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-Strips and little dressings on and then she’ll wake up and go to the recovery room for a couple hours, and we'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’s being woken from anesthesia. Everything went well with the surgery. The only surprising finding, really, was in the beginning with all the adhesions from the splenic flexure of the colon up to the abdominal wall. You always see some attachments, but this was much more than usual, and I'm not sure if there's been previous inflammation in that area. We didn't see anything abnormal other than that, but in any case, once we took those down, everything else was pretty straightforward and found 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, but I'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 see how much of her hypertension responds to the operation. I'm hoping that she can go home today - a lot of these patients can - but we'll see how she does in the recovery room and for a couple hours afterwards. And she'll, in any case, monitor her blood pressure at home, and I will keep touch with her closely to make sure that she's on the right medications over the next couple weeks as she recovers from the surgery.