Transperitoneal Laparoscopic Right Adrenalectomy for Cortical Adenoma

CHAPTER 1

Our patient today is a 58-year-old female, who has long-standing hypertension. She's been on three medications for a long time and also has had hypokalemia - pretty significant - with potassiums as low as 2.3. So her primary care doctor did an evaluation and found her to have hyperaldosteronism. Her serum aldosterone was 24. Renin was suppressed at less than .6, so the ratio was well over 30, which essentially confirmed the diagnosis of hyperaldosteronism. She then had a CAT scan, which you can see here. And - going from above, coming down, you can see the adrenal glands coming into view, and on the right side, you see this 2.6-cm lesion - clearly seen in the right adrenal that has characteristics of a cortical adenoma. On the left side, there was also a lesion. This was smaller - 1.3 cm - again, consistent in terms of imaging features with a cortical adenoma. So, she had bilateral cortical adenomas by imaging. One was 2.6 cm. The other one 1.3 cm - clearly needs adrenal vein sampling. We do that in most cases anyway, but obviously, in this patient, there's no question we need to determine which side might be responsible for her hyperaldosteronism. So her adrenal vein sampling was done, and the results were very - very clear-cut step up on the right side. So her peripheral values of aldosterone to cortisol was 66/26. Ratio is 2.5. On the left side, the aldosterone to cortisol was 78/197 with a ratio of 0.4, whereas on the right side there was a very marked step up: aldosterone of 3800 with a cortisol of 692. That ratio was 5.5. So when we do the ratios right:left, the aldosterone:cortisol - 5.5 over the left side, 0.4 - the ratio was 13.75 - clearly over 4, which is usually the cutoff we use. And so very good result in this patient suggesting that the right-sided adenoma is the one that's the culprit in causing her hyperaldosteronism. So our plan today is for a laparoscopic right adrenalectomy. So the key steps for this operation: She'll be in the supine position, intubated, and put under general anesthesia. We'll then put her in a lateral decubitus position - left lateral decubitus position with the right side up. We use a bean bag inflation device to make sure that all the bony prominences are well-padded and that she's in good position. The bed is flexed so that we maximize the exposure to the abdomen. And then I use a right paramedian open approach. So we put the Hassan cannula in the right paramedian incision, and then we'll use a 12-mm trocar for the epigastrium, and I use an Endo Paddle through that port site to lift up the liver. The Endo Paddle works very well for that purpose. And then two 5-mm trocars along the right costal margin to do the dissection. We'll use the harmonic scalpel and mobilize the liver, lateral attachments, and inferiorly, and then basically circumferentially dissect out the adrenal gland, dividing the attachments to the diaphragm and retroperitoneal muscles, medially we'll separate it from the vena cava, and then isolate the adrenal vein, which we will clip twice on each side, and then remove the gland completely, place it into an Endo Catch bag, and bring it out, and then close the port sites. Adrenal surgery is of course not that common, and like any operation it's important to have experience and sort of confidence to be able to do the operation safely. The risks on the right side mainly from a technical standpoint have to do with the vena cava and the short adrenal vein. On the left side, the adrenal vein is longer and of course is coming off the renal vein, so it's a little bit easier from that standpoint, but on the other hand, the dissection and exposure of the glands is more complex because you have to move the spleen and pancreas out of the way and track them, and so it's a little more difficult to get to the adrenal gland. But, I think this operation in particular - it's not so much the technical aspects as the sort of pre-op evaluation and making sure that you are doing proper diagnosis and patient selection especially for something like aldosteronoma, but even other conditions of the adrenal gland - so important to be familiar with how you establish the diagnosis, whether it's Cushing's or hyperaldosteronism, and how you determine whether a patient is going to benefit from surgery. In this particular situation with hyperaldosteronism, obviously, you need to be very confident that you're taking out the correct adrenal gland, that it's the side that is producing the excess aldosterone and is likely to help the patient. The last thing we want to do is to subject the patient - anybody to an unnecessary operation.

CHAPTER 2

So we're going to - let's see. Here's the - rib margin. Here is her anterior superior iliac crest, or the iliac crest. So, what we're going to do is go paramedian, near the umbo - maybe about here. We want to let, you know, the pannus drop down a little bit, and then we're going to put a 12-mm trocar somewhere here for the Endo Paddle to lift the liver up, and then two 5-mm trocars over there. Do we have the local anesthesia?

You don't want to use the Bovie? You can use the Bovie. You can show people how to use the Bovie.

CHAPTER 3

You just cut - two narrow Richardson's, please. Yeah - maybe... A little bigger? Like by a millimeter. Okay. Yep, so - you want to go that way, and you can hold this, I guess. Can I get a Schnidt, please? Go ahead. This is all the local anesthesia. Okay, just... Okay, hold on. There's white, right? So just a small opening in the anterior sheath - okay, good. We'll take 0 Vicryl. So we'll put a figure of eight on both sides of the opening - longer needle driver, yeah. Let's see, what did you get? You got the upside? Yep. Oh... Now you want me to go...? Yeah, no, you want - you know, a figure of eight on the upside, right? Yep. Hold that up - snap and scissors, please. Look, it's long, It's okay, I don't like the short ones. Let's see, cut that. And then another one, please. You're in the way. There we go, like - okay, like that. Okay. And another Schnidt, please. So here's the - you can see the white. Yep. And a knife. And then the Hassan, please. Hold on. Okay, so we're no question about that - hold on a second.

I just want to make sure of that so we have no question we're going to go like this - right there and like this. That way we know... Is this a good line? Yeah, that's fine. Go ahead. Keep it pushed in - just so we don't lose that, okay. Hold on, make this - put it in as far as it will go in terms of getting some security. Yeah - okay, and then you can take these. Can we get high flow on the CO₂, please?

Gas is on. Thank you. Hold on. And then wrap it.

Yep, you'll see. Okay, take that, and then let's put the scope in. Can we have the room lights off, please? So then we're going to look up here. The liver looks good, nice and healthy, right? Yep. Can you look down at the liver for a minute - just one? Look down - yeah. And I think we need a little bit of focus. And I'll take the local anesthesia, please. Yeah, there we go.

Okay, watch that. Knife and a 12-mm trocar. So on the right side, I use a 12 trocar in the epigastric because I like to use the Endo Paddle, which works very well in retracting the liver. It's got a broad base, the felt is, you know, soft material - I'll take the Endo Paddle, please - that doesn't dig into the liver, but it does require a 12-mm trocar. On the left side, I just use the fan retractor on the spleen and pancreas to pull that over. Okay, so what we're going to do is... Let's see. This is a little stuck there. We may have to... Take those down? It's possible. Usually, you don't have to take anything down in terms of the colon, but in this particular case, it might be a little stuck, we'll see - right there. Huh, interesting. You usually don't have to do that. She had a gallbladder in 1992. Yeah, okay. So, why don't you - let's put in the other trocars. Okay. So, let's see, go farther lateral on the first one just to sort of see where... This is where you had marked it. I know, but don't, yeah - Yeah, well don't go - yeah, but it doesn't matter where I marked it. Go out more lateral. Can you go out farther lateral? This is as far as - with this I can go more. You may want to do that out there - not that far out. A little bit closer in - like maybe just up - yeah, like there. Okay, try that. So, some local. Okay, good - and then we'll get another one sort of in between. That's - so this is why I like to go - do it from over there, you know? I mean, with a couple of stands you can, you know, it works. Okay, yeah, we can try that. Well, I don't know, I like it that way, but... Where do you want this, here? Closer to us - closer, there I think, yeah. Okay. Good? Yep. So on the left side for an adrenalectomy, I always take down the splenic flexure of the colon. You sort of have to do that to get adequate exposure. On the right side, you almost never have to take down the colon at all. This is only because of adhesions from the prior gallbladder surgery I guess.

Okay, go ahead. So there's a fair amount of tension on the tissue already, so you can just pretty much go ahead and take these down. Mm hmm. Mm hmm, it's on a lot of tension so just - yep. Yeah, that's the gallbladder fossa, right? We don't - we don't really need it - okay, so let's go over here.

CHAPTER 4

So you already can see the - hold on a second. The adrenal - very easily. You see it? That's the adrenal, and here's the IVC. There's the kidney. Maybe a cyst on the kidney - is that what that is? In any case, can you hold the scope for a minute?

I'll open up this Endo Paddle, so it gives you - again, it gives you a nice, broad view - exposure, so - often - let's vent a little bit - often, I start by taking down the lateral attachments of the liver. I think we should do that a little bit because it's already pulling. I don't think we have to do too much here, but - in this particular case, but it'll just allow us to - so just push down and you can just get some of those attachments. So I bring the Endo Paddle and just sort of bring it up towards me a little bit. This is the end of my... Yeah, yeah. You might be able to put the trocar in more. Okay, yep. Yeah, so let's get the suction/irrigation and just clean that out for a second.

Let's continue where - where you were and just take down the peritoneal attachments to the liver inferiorly. Careful. So you're going way up, so we can start out lateral and just - you want to be just a millimeter or two away from the liver, yep. Good. And just get in that groove and there you go - zip, zip. So we're going to lift the liver up and get to the superior aspect of the adrenal gland down to the retroperitoneal muscles, diaphragm. So with the other instrument, you should push down on the adrenal gland, just carefully. Yep. And you want to almost bring the gland towards you by pulling - yeah, yeah, yeah, and I'm going to get this retractor better, and then we just keep going until we get down to the muscle, down - lower, down - well, I mean, down - in other words... Closer to the adrenal? Yeah, just stay away from the liver a little bit - yep, okay. Mm hmm. You want to sort of head towards the back - posterior. Towards her back? Yeah. Her back, which is straight down. Yeah. I can't tell if that's a vessel. Yeah, careful, careful. That's - okay, that you can do, that's fine. So again - you got to - stop for a second - you have to push down on the gland - yep - so that we make sure to just pull it up. Because, I'm not - so that looks like a little accessory vein to the cava, which you often see, so we're going to stay on our side of that. Okay. So you can get right in that groove, but I would go up right there. Yep - and just adjacent to that - exactly, right there. But use your other instrument to push down, so - and then the - you can use the harmonic to - that's fine - you can use the harmonic to push a little bit to show you the - show you where you are. Up - go up higher - so it's right... Here. Push away, yes. You want it to go in different directions: one down, one up. And then - and then grab it if you can. So, well, that's bleeding. Okay. So, let's go out here, lateral. Here? Out farther lateral - back, towards the back. Here? Yeah. And you got to go beyond the gland. The gland is right there. The gland's right here? Yeah, so you have to go beyond the gland. Right here? Yeah, and you want to pull the gland towards you. Yeah, that's it. And then go deep. Pull it - pull it and go deep. Here? Out lateral to find the muscle. I see. I see. See the muscle back there? Okay, that's what you want to do. Get beyond it - get beyond it, and pull it - pull it towards you. Yes! See how it comes off? Yep. It's the same thing on the left side, how we can - you can sort of sweep it off of the retroperitoneal muscle and diaphragm. Mary, could you bring the screen closer to me? So bring it down. Yep. And then keep coming - you got to keep coming down to - inferiorly, yeah. Okay, so now we can... You see the kidney here, right? Let's start making the - find the cleft between the kidney and the adrenal, so... I'm going to score a little here. Yep. Okay? Mm hmm. Yeah. Right? Keep going out lateral - go out lateral. Here? Like here? Yeah. Yeah, chop through all that - yep. And again, you know, you have to start making your way deep to the muscle. So not on top, you have to go down deep. Down more? Yeah, but you can get all that stuff all the way out to the - yeah. Okay, got it. Score all the peritoneum here. Yeah, yeah. So you have to kind of dig in there with both instruments - reverse chopstick - one goes one way, one goes the other - and then dig in. And dig. Go ahead, dig - you're just rubbing on top. You're not getting - so dig - dig into it with the instrument. Go ahead, get it. You're not, you're not - I mean, grab it - grab it with the - Grab it? No, with the - with your harmonic so you can get it. Oh, like actually - oh, like actually... Dig in, right, right. I thought you wanted me to bluntly dissect. Well, you can only go - I mean, if you can, but it's not - you're not making progress if it's sort of a... So you want to get deeper, yep. I see. Yeah. Can you vent, Connor? Thanks. So go in there. Dig in one way and then the other. Here? Yeah. More lateral still? Well just - that's fine. You're good, you're good, you're good. I just like to do reverse chopstick if that makes sense. Like this? Yeah, but down, deep, deep, deep, deep. Yeah. Yeah, it's the angles. Yeah, I know it is. Go ahead and now grab it. See, now you can grab all that stuff. Yeah. Yeah, keep pulling... I'm going to get the stuff in the foreground, I think that's... No, no, get - no, no, no - just keep going. You're going to get - your going to be good. You're going perfectly - yep. Before you know it, you're going to be down to the muscle. Okay. So, go ahead, just keep going deep. As long as you're going through that fat, you're in good shape. Okay. All right, so keep going lateral, yep. Sometimes I can help a little bit with this, and then go deeper - go deeper. I know, I know, I - you're going to get it, but I want you to... Like I've been saying all day, I trust you, Dr. Hodin. Go ahead, yep. See, muscle! I see it. See, once you get to the muscle, then it just - and then it just comes right off. It's really simple. Yep. So I'm going to go and just kind of help you a little bit with this, and then it just - yeah, you don't have to be out that far. I'm just going to... Okay, that's fine. Coagulate this. But, we're just... Yep. Yep, and then you can get behind there and get some of those attachments underneath, yep. Do you see the liver? The liver's right here, you want me to get that? Just get it - it's just on a lot of tension, so we're just going to relieve that a little bit. Okay, and then that gives us a better view of - you know - careful, we don't want to get the diaphragm. Yep. Good. All right. Okay, so now, if we go back to this, you can - can you just get the adrenal back down, yep. Okay, so now, I'm going to straighten things out a little bit. Yeah, don't grab. We're going to want to get between the cava and the adrenal, okay?

CHAPTER 5

So, I'm going to go in carefully. So here's cava. Here's the adrenal gland - there, you can see there's a tumor right there, right? It's bulging out a little bit. So we do have to get the peritoneum. Once you make an opening... Just one second, I want to just get in there. So I feel like we're a little - can I get the clip applier, please? You mean the 5-mm one, or do you want... Yeah, 5-mm clip applier. That shouldn't be anything there really, but... You can see... It's a little over it, like, you can see the cava right under you. Yeah, so my point is here, well - are we straight? I feel like we're not straight. So you can go in with both instruments, and you push the cava one way. And I go deeper with the suction and go the other way, and if you keep going, you're going to - yep, see, I'm going one way, I'm making it a little tunnel, but... And I'm pushing down to the muscle. So this is all just - extra adrenal - periadrenal fat, and it's going to get us down to the muscle - eventually. Aren't you nervous about touching the cava with the hot instrument? Or not really? Not really. I know people worry about that a lot, and I've never - so there's muscle. Yep. Actually, this could be the adrenal vein right there, right? Yeah. Because this is all - so this is actually - this is probably the adrenal vein that's - we're not seeing it so perfectly, but... Oh, maybe not - no, maybe not, maybe not. This looks like it, here. Yeah, maybe it's just - and there's more adrenal up there. So, I'm going to just go like this for a minute. See the adrenal tissue under there? So again, I mean, I - you don't have to do this all now, but I'm just doing it to make the point: how easy it is to get this because if you go out here, look. This is going to be very easy to take the rest of that. Yep. I'm going to just put a... Clip on that? Clip on just because - sort of in case. So it loads. Can I have the harmonic back? Do you think that's the vein? I don't, honestly. I guess we'll find out. Didn't seem very - like there's much of a structure to it. So you see how this just... Yep. It's all incredibly safe. Yep. You can lift it up. Yep. You can't hurt anything. Right. We're going to be able to get all that. Now... That's our vein there, I believe. Now the vein - so there's adrenal. The vein's going to be in here, right? Oh, there - there it is - right there. Yeah. So again, I think we're not entirely... Let's get more - pull up on liver. Yeah, there you go.

So there we can see the vein more clearly. Adrenal vein's very easy to get once - once you see it, it's just - there's always a space there that's easy to delineate so you can just sort of go like that. I'm just making it a little more clear, but we could clip at anytime. So it just lifts off the retroperitoneum so easily. Okay, so... And this all - again, it's all just... Okay, you want to come and take the vein? Sure, or you can do it. It's fine. You don't care? No. Okay, I'll take clips. 5 mm is okay? Yeah, I do it just because we have the 5-mm trocar. So, we'll make sure one nice one on the vena cava, another one - on the cava side. Uh, let's see. I should have gone up higher. Okay, that was not - yeah. Scissors, please. Oh, that was not exactly what I was planning. That's why you should have done that. Let's see. Let's make sure that we're... Yeah, below your clip, on the vena cava side, it's like - was oozing when there was tension on it, so... Yeah, it's fine. Harmonic, please. It's basically done. So we just get the remainder of the attachments. We still have to take it away from the liver a little bit but let me just - So now let's see where - where it's meeting the liv - the kidney right here. Mm, yeah, there's a big vessel there though. Shouldn't be. Where? It just keeps pulsating right under there. Where do you mean? Here? Yeah. Well that's going to be the renal artery. Yeah, I'm just saying... Yeah, so we're going to stay away from the renal artery, so I'm going to push the adrenal sort of up and away, so we make sure to stay away from the hilar vessels. So I'm kind of getting under and trying to push it away. Can you clean that for me, please? So let's see what we've got here. You've got - that's - where you're going to take it off the kidney, huh? There you go. Yep, and actually out this lateral, you know... Here? Yeah - you really can't hurt anything, you know, once you're beyond where the renal vessels are going to go in. I mean, there can be a superior branch that's - you can see it under there - but like you said pulsating, but... Yeah. And do you still like to use this instrument for this? Well, to keep the - at some point, you can just grab, you know? Right, exactly. When you sort have enough, but go ahead, you're right there. Yeah, you see the kidney? The kidney is right here. Yeah, is that - what is - wait, what is that right there? What is that? It's just a... A vein, but I think that's... How is that possible? Yeah, I think it's just. Yeah. It's just a fold? It's just a fold of - okay. Go ahead. Yeah, it should just be - there shouldn't be anything, so - but go ahead, let's go. Okay. Because my... Get close to the - yeah, get close to the adrenal. The adrenal's up here. Underneath there, yeah. Uh huh. Mm hmm, just lift it up, yep. Can I switch this for a grasper? A grasper, yeah. Just suction out once. While you're there, just suction it out, just to clean it a little bit. So grab down here. If you grab - grab down - no, grab right there. Yeah, like this, just come here, come right up, yeah. And then I'm just going to go here. Go chop, chop - yep. Mm hmm. Can we have an Endo Catch bag? Okay, grab it. That's it. Is that it? Yep. Let's see. Suction/irrigation. Let's just - can you pull - pull it - make sure it's all completely detached. Is it? It definitely is, yeah. Yeah, okay.

So we'll just - this looks good. There's the cava. There's our two clips. Mm hmm, just suction out that little - yep. Do you want me to irrigate? Sure, go ahead. Yep, that's fine. Looks good. All right, so I'm going to let the liver fall down. Okay.

CHAPTER 6

And if you can hold the scope for just a minute. Mm hmm. I'm going to take this Endo Paddle out. I love these cases. And then we're going to take the scope, put it into the epigastric site, and we'll take the Endo Catch bag. So... And drop it in the bag. Yep, that's fine. And then, if you could just close it up. Here, I can hold the camera. Okay. Okay so - Kelly, please. Scissors. There's that. Let's just take those other trocars out under direct vision. That looks fine. This looks fine. Okay, so we're going to take this. And room lights on, please. All right, so we'll go like this. And then we'll see. Oh, okay. Can I get a sponge and a scissors?

CHAPTER 7

So we're going - I'm going to take a look at the lesion. Can I get a knife, please? So, this is an aldosteronoma, we believe, so we expect it to be a cortical lesion. And that's what it is, clearly - can I have another - actually, I'll just - clearly, that's a nice, yellow, lipid-rich cortical adenoma. So, it's - it was supposed to be 2.5 cm, right? That's - about correct, and then let's just see here. The adjacent, normal adrenal will be out here. You can see that little, thin... Oh yeah. Can you see it there? Oh, that's so cool. You can see the - cortex and then the line - dark line in the middle of the medulla. So this is a nice cortical lesion. Okay, so we'll put this in the pathology cup. Okay, that's right adrenal gland, and let's see - can I have a wet and a dry, please? And two narrow Richardsons and a 0 Vicryl. We'll close up the fascia.

CHAPTER 8

All right, let's put a stitch above, below, and then we'll tie these together. Mm hmm. So we will watch her in the recovery room for probably 3 or 4 hours, and if she's okay, she can go home today. Otherwise, if there's any question, we can keep her overnight, but it's pretty safe to send these patients home. Pull it through. Oh, wait, I'm not. Oh, okay. Just so we don't... Okay, I just wanted to go across. Uh huh. Can I get a sponge, please? So, that's the apex, right? Mm hmm. Did that get both sides? Sort of did, huh?Yeah. Yeah, I think so. We'll get... Let's see here. So then we'll go like this. I'm going to come through the middle. Mm hmm. I like how it was so short. I know. I've done them - I mean, honestly, if - I've done this operation in 20 minutes. It's not always 20 minutes, but you can see how easy it can be, I mean…

CHAPTER 9

So we just completed the laparoscopic right adrenalectomy. Everything went fine - it was a pretty straightforward case. We saw the lesion in the adrenal gland even laparoscopically, and then once the specimen was out, sort of confirmed that this was as expected - about a 2.5-cm cortical adenoma. No real surprises from the standpoint of the dissection or the anatomy, and she did well throughout the case. Usually, I send these patients home, assuming they don't have significant medical comorbidities. The incisions, the port sites, are essentially the same as we do for laparoscopic cholecystectomy, which of course is done routinely as an outpatient, so as long as there aren't significant either comorbid conditions or sort of an endocrine reason from the standpoint of the adrenal tumor to keep the patient in the hospital, I do tend to send most of these patients home the same day and keep track of them closely with telephone calls tonight and tomorrow. And the patient was anxious to go home, so we'll see if that works out. Of course, she's going to take her blood pressure at home. I usually have patients take it twice a day and record so that I can see the levels but also her primary care, or whatever medical doctor's taking care of her blood pressure meds. We'll send her out on reduced medications, maintaining the beta blocker for now. And we'll see what happens in the long run with her blood pressure and her potassium. We're hopeful based on the adrenal vein sampling that this is going to cure her hyperaldosteronism, and ideally, she'll be able to come off all of her blood pressure meds and certainly the potassium supplements, but only time will tell whether there's any element of essential hypertension and whether she'll need any blood pressure meds at all, but we're hopeful at this point, and we will see how it turns out.