Dr. Pau Moreno

Step by Step: Laparoscopic retroperitoneal left adrenalectomy

Case The patient is a 52-year-old woman with a previous medical history of: In the Endocrine evaluation, Hypercorticism was found. Free urinary cortisol and plasmatic cortisol levels had increased, and ACTH was low. A 5 cm left adrenal tumor was found in the CT scan. Treatment The patient is in the prone position. Three trocars of the size and location shown will be used. The spine is marked in the middle. The 11th and 12th ribs are marked too. We will perform 3 incisions on this patient, the first incision being the open access under the 12th rib. With the finger you can access the retroperitoneal space, which will allow us to place the rest of the trocars safely by touch. First the 5 mm trocar is placed below the 11th rib and then the 10 mm trocar is placed near the spine. The idea is to go beneath the 12th rib and access the adrenal gland tumor from the back using a 30º laparoscope. We will place the camera in the middle. This is Gerota’s layer, which we must open, and the kidney and the adrenal gland are behind. We have the instruments just somewhere in the depth and now we need to create the space. The first landmark is the kidney so the first thing we do is just dissect down to the kidney. We push down the fatty tissue like this. The first important maneuver is to dissect the upper kidney pole or the kidney backside as you can see. Once we have mobilized the kidney and pushed it down a little, we will have an excellent access to the adrenal gland from the back. It is at this time that we will perform dissection of the lower pole of the adrenal gland. Now we are dissecting the adrenal gland in a lateral way. On the left, you can see the peritoneum, a blue layer. The spleen is behind it.  We continue with the dissection of the adrenal superior pole which is much easier. Once the entire gland has been mobilized we will look for the adrenal vein. When we find the vein we will section it with the energy device. We proceed to irrigate and clean the small amount of blood. We extract the gland in a bag and place a drain that is removed after 24 hours, when the patient is discharged. We encourage you to visit our open classroom section to see all the details.