Robotic-Assisted Left Adrenalectomy

Case Overview

Laparoscopic adrenalectomy (LA) is currently accepted as the standard treatment of adrenal benign tumors.^1,2,3 However, laparoscopic procedures, including LA, present certain limitations for surgeons. These drawbacks include an orientation error resulting from camera holding and manipulation by the assistant, restricted range and freedom of instrument movement, inherent hand fatigue or tremors, and a restricted two-dimensional operative field.^4,5

Current evidence supports the use of robotic surgery as a method of minimally-invasive treatment for adrenal masses. Recent studies indicate that robotic adrenalectomy (RA) can be effectively performed with operative time and complication rates similar to LA.⁶ The robotic system has several advantages over laparoscopic surgery such as three-dimensional optics, magnified view, freedom of movement for operating instruments due to improved moving capacity of the robotic arms, tremor filtering, and a comfortable seated position for the operator during surgery. In addition to periprocedural benefits, RA can provide a reduced duration of hospitalization and a lower incidence of postoperative complications.⁷

However, RA, compared to LA, often involves higher costs due to the expensive robotic equipment and may require longer operative times. The increased duration of the procedure can be influenced by factors such as docking time and the experience of the surgical team. The decision to choose RA should be made with the aforementioned factors considered.⁹

RA requires careful case selection, just like any other robotic procedure. Indications for RA are similar to LA and include benign adrenal tumors larger than 5 cm in size, smaller lesions with potential to develop into malignancy, benign pheochromocytoma, and myelolipoma. Cases of RA for adrenal carcinoma and metastasis have also been documented.⁸ Contraindications for RA include the presence of infiltrative adrenal masses, and involvement of large vascular structures or neighboring organs.^9,10

Preoperative preparation, positioning of the patient, and creation of the port sites are the same as for LA. The left adrenalectomy procedure involves the utilization of four trocars and four entry ports, respectively: a 12-mm port for the camera, two 8-mm ports for the robotic arms, and a 5-mm port for manual assistance. The patient is positioned in a full lateral decubitus position with the left side facing upward and in a flexed position.  Special attention is given to pressure points, ensuring they are adequately cushioned with pillows.

The RA is performed under general anesthesia. Carbon dioxide insufflation begins with the insertion of a Veress needle in the left upper quadrant at a specific point located 2 cm below the left subcostal margin in the midclavicular line. Initially, the gas pressure is kept low, gradually increasing as needed. Once pneumoperitoneum is established, a 12-mm trocar for the camera port is inserted at the lateral border of the rectus abdominis muscle just below the costal margin along the anterior axillary line. Following the first port insertion, the 10-mm rigid laparoscope is inserted via this trocar to carefully inspect the abdominal cavity under direct visualization. Inspection of the organs is crucial to verify the absence of unintentional injuries upon port entry. Anatomical landmarks such as the descending colon, omental fat, the lateral segments of the left liver, ligament of the colonic splenic flexure, and stomach are identified. Following the exploration process, other ports are inserted under direct vision while local anesthesia is administered. An 8-mm robotic port is positioned 2 cm below the costal margin and 8 cm superior to the camera port along the lateral border of the rectus muscle or midclavicular line. A secondary 8-mm robotic port is positioned at least 2 fingerbreadths from the anterior superior iliac spine and 8 cm away from the camera port.

An additional 5-mm port is placed below the second 8-mm port. This setup ensures ideal triangulation with the camera in the middle and two instruments for energy devices or graspers, along with an assistant trocar for retractions. Adjustments are made as needed, and repositioning is done if necessary. The robotic system is prepared, and the camera is maneuvered to provide optimal visibility.

Once positioned correctly, the robotic arms are docked. The two arms are positioned for optimal access. The double-fenestrated grasper, known for its long jaw and gentle grip, is used to retract organs such as the spleen or liver. Adhesiolysis is performed to address adhesions between the spleen, left lobe of the liver, stomach, and omental fat. The inferior phrenic vein serves as a landmark for left-sided colonic mobilization. The lateral attachments of the spleen, as well as splenorenal ligaments, are divided. The tissue plane between the pancreas and surrounding structures is identified and dissected to mobilize the pancreas and spleen medially along an avascular plane. As dissection progresses, the spleen and pancreas are gently retracted to allow access to the desired area. The splenic vessels are preserved, and the phrenic vein is identified and followed through the retroperitoneum. Due to the potential presence of the adrenal tumor in this region, a thorough dissection is performed until the adrenal gland becomes visible. The kidney is identified, and dissection along the border with the adrenal gland is initiated. The perinephric fat is shaved off to ensure a clear margin on the adrenal tissue once the fascia is reached. The identification and dissection of the left renal vein is essential because the adrenal vein is a branch of it. The electrocautery technique is employed to identify and ligate the left adrenal vein. After achieving proper control over the adrenal vein, the adrenal gland is mobilized in a circular manner. This process starts at the upper pole of the kidney, moves towards the diaphragm, and connects the posterior surface of the adrenal with the psoas muscle. Layers of fat are left on the surface of the adrenal gland to use as a handle, thereby minimizing manipulation of the gland and avoiding fracturing it. The adrenal gland is carefully dissected away from surrounding tissues using the harmonic scalpel, and attention is given to preserving nearby structures such as the renal vein, ensuring it is carefully identified and protected during the dissection process.

As the instruments are withdrawn, the surgical field is carefully inspected to confirm adequate hemostasis and ensure no structures are inadvertently injured. Following specimen removal, the fascia is closed using an Endo Close device with Vicryl sutures. Interrupted sutures are placed to approximate the edges of the fascia, followed by figure-of-eight sutures to provide additional reinforcement and strength to the closure. After the evaluation of hemostasis by gradually decreasing the pressure of the pneumoperitoneum, the assistant proceeds to introduce a laparoscopic entrapment sac, into which the specimen is subsequently placed. Afterward, the robot is undocked, and the specimen is extracted. Following the irrigation and suctioning of the operative site, the trocars are removed. The skin is meticulously closed using a combination of interrupted sutures and a topical skin adhesive to ensure a secure and cosmetically pleasing wound closure. No intra-abdominal drains are left after completing the RA.

Upon examination of the extracted 1.5-cm specimen, it exhibited typical characteristics of aldosterone-producing adenoma, including a golden tan color, well-circumscribed borders, and surrounding normal adrenal gland tissue and fat. Postoperatively, the patient will be admitted for observation overnight and discharged the following day.

In conclusion, RA is characterized as a safe, feasible procedure, resulting in desirable outcomes while affording ease to the operating surgeon.¹¹ The detailed demonstration of the aforementioned surgical procedure in the accompanying video provides a thorough understanding of the issues involved. This video is an invaluable resource for medical professionals seeking to delve into the latest advancements in robotic adrenal surgery, offering comprehensive insights into the nuanced techniques and emerging trends in the field.

Disclosures

The patient has given their consent for the resident to be involved in the surgery. We have not applied for and have not received any funding for the preparation and publication of this article.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.