Transperitoneal Approach

Following general anesthesia, a nasogastric tube and a urinary catheter are placed. The patient is positioned in the modified 45° flank position with minimal flexion of the table. All the pressure points are well padded. Once strapped to the table by a wide tape across the hips, the patient is rotated toward the surgeon for another 30° to 40° to facilitate spontaneous, gravity-induced displacement of the bowel off the kidney. A 12-mmHg pneumoperitoneum is created, and the CO2 is prewarmed with a heat exchanger integrated in the insufflation tubing to prevent catecholamine release due to cold stress. The primary port (10 mm) is placed pararectally 5 cm above the umbilicus on the affected side. Two secondary ports (5 or 10 mm) are placed in the ipsilateral subcostal area to form an equilateral triangle. Three trocars are usually sufficient on the left side. An optional fourth trocar can be placed if necessary, especially on the right side. The authors routinely use a robotic arm (AESOP 3000®a) to hold the camera and to provide a steady good quality picture. On the right side, after retracting the liver anteriorly, a vertical incision is performed on the posterior peritoneum along the inferior vena cava and continued laterally at a right angle, parallel to the lower margin of liver (Fig. 3). Because the adrenal gland lies directly under the peritoneum, this maneuver usually exposes the gland without the need to mobilize the colon or the duodenum. The right main adrenal vein has a consistent location lateral to the inferior vena cava. The left adrenal gland requires wider mobilization of the descending colon and the spleen. As such, the peritoneum is incised along the line of Toldt and the incision is continued upward along the spleen to allow medial descent of the spleen away from the adrenal gland. The splenocolic ligament may be incised as needed. After adequate exposure the adrenal gland, intraoperative laparoscopic color Doppler ultrasound

FIGURE4 ■ Intraoperative ultrasound showing the liver and solitary tumor mass and adrenal vein. Abbreviations: L, liver; AG, adrenal gland.

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The cortex attached to the surrounding connective tissue via a wide strip of undisturbed tissue containing small arteries and veins is spared.

with 7.5-MHz transducer is a valuable adjunct to image the gland, the tumor, and the adrenal vein (Fig. 4) (38). The dissection of the tumor depends on its location and relationship to the vein. The tumor margin has to be identified and partial removal of the adipose tissue surrounding the tumor may be necessary to clearly delineate the tumor. The tumor is dissected with a small rim of normal adrenal gland to achieve an oncologically safe removal. The adrenal gland parenchyma should not be directly grasped, because of easy friability leading to bleeding. Various techniques of dissection have been proposed. However, the authors prefer preliminary bipolar coagulation along the intended line of dissection and cutting with endoscissors, which allows precise dissection. Harmonic scalpel is also an effective tool to divide the adrenal gland while securing hemostasis (39). The use of a vascular stapler, although feasible

(40), does not allow precise dissection. Suture ligature has been used by Walther et al.

(41). Every possible effort to spare the adrenal vein should be made, although it can be sacrificed if it is deemed necessary for definitive tumor clearance.

The cortex attached to the surrounding connective tissue via a wide strip of undisturbed tissue containing small arteries and veins is spared. The cut surface is covered with fibrin glue or similar hemostatic agents as a precautionary measure to avoid secondary bleeding. The postoperative viability of adrenal remnants after main adrenal vein division has been elegantly shown with 11I adosterol scintigraphy by Ikeda et al. (42). The tumor is entrapped in an impermeable retrieval bag system and extracted through the primary port. All port sites are closed with fascial and subcuticular sutures after leaving an optional drain at the discretion of the surgeon.

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