Posterior Retroperitoneoscopic Adrenalectomy: Indications, Technical Steps and Outcomes

Description:

This book will offer for the first time a step-by-step description of the posterior retroperitoneoscopic adrenalectomy, a minimally invasive technique, moving the gold standard of laparoscopic adrenalectomy towards the retroperitoneoscopic approach. Detailed information about the technique, the advantages over other approaches, the technical steps, the potential complications and how to solve them, outcomes, and robotics, will be offered to readers.

This practical guide will be of great interest for all general surgeons and urologists already performing adrenal surgery, and for those that wish to start performing adrenalectomy.

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Preface

Minimally invasive surgery has great advantages for patients compared to open surgery. In adrenal surgery, this is no exception. Although the transperitoneal laparoscopic approach has become the gold standard since its first description in 1992, the posterior retroperitoneoscopic approach provides benefits for both patients and surgeons.

Fifteen years ago, I started using the laparoscopic approach in several different areas, namely colorectal surgery, hepatobiliary surgery, laparoscopic repair of both ventral and groin hernias, and diaphragmatic hernia repair. Since 2005, I have also been using minimally invasive surgery to ligate insufficient lower limbs perforators to heal varicose ulcers. All this has given me a broader perspective of the advantages of every minimally invasive technique.

In 2014, I met Professor Dr. Martin Walz and had my first contact with posterior retroperitoneoscopic adrenalectomy. Not only did I have the opportunity to work with him, but also learned how to perform posterior retroperitoneoscopic adrenalectomy. It was love at first sight, and I immediately thought this great technique could revolutionize adrenal surgery. This approach gives direct access to the adrenal gland, has no incursion into the peritoneal cavity, has minimum risk of viscera injury, and promotes fast recovery. Despite its advantages, many surgeons do not use it because they are not familiar with the retroperitoneum space and are not used to the posterior anatomical perspective. This book will change that.

In 2015, I adopted the posterior retroperitoneoscopic adrenalectomy as the gold standard for adrenal surgery. Since then, I have published data supporting the safety and feasibility of this technique, and I have also proved that a shorter learning curve is possible if surgeons have laparoscopic skills acquired during other procedures. So, there is no reason for surgeons to keep resisting the retroperitoneoscopic approach. In several publications, videos, and scientific lectures, I have tried to demystify the technical difficulties described by some surgeons and contend that learning from an expert is the best way to begin using a new technique.

All the chapters in this book were written by a group of international specialists (surgeons and anesthesiologists) with vast experience in the technique. By sharing their knowledge, they make this book the “expert” a surgeon needs to initiate the “back door” approach to adrenal tumors.

This book intends to provide all general surgeons and urologists interested in adrenal surgery with the knowledge they need to start performing posterior retroperitoneoscopic adrenalectomy safely and effectively. In an easy-tolearn format, it presents the reader with information about anatomical key points, indications for the retroperitoneoscopic approach, possible complications, and limitations of the technique. A step-by-step description with tips and tricks will help surgeons start their adventure in the posterior retroperitoneoscopic approach. The learning curve and the outcomes presented will show the reader why all general surgeons and urologists should prefer this minimally invasive technique. This book aims to contribute to make posterior retroperitoneoscopic adrenalectomy the new gold standard in adrenal surgery.

Table of contents :

Preface
Contents
Contributors
Abbreviations
1: Anatomy of the Adrenal Gland
1.1 Introduction
1.2 The Adrenal Gland
1.2.1 Anatomical Landmarks and Topographic Anatomy
1.2.2 Arterial Supply
1.2.3 Venous Drainage
1.2.4 Lymphatic Drainage
1.2.5 Innervation
1.3 Anatomical Considerations in Posterior Retroperitoneoscopic Adrenalectomy
1.3.1 Retroperitoneum
1.3.2 Abdominal Wall (Posterior and Anterolateral)
References
2: Indications for Adrenalectomy
2.1 Introduction
2.2 Posterior Retroperitoneoscopic Adrenalectomy in Overproduction Adrenal Syndromes
2.2.1 Excessive Production of Aldosterone: Hyperaldosteronism
2.2.2 Excessive Production of Glucocorticoids: Cushing’s Syndrome
2.2.3 Excessive Production of Catecholamines: Pheochromocytoma and Paraganglioma
2.3 Posterior Retroperitoneoscopic Adrenalectomy in Adrenal Malignancies
2.3.1 Adrenocortical Carcinoma
2.3.2 Malignant Pheochromocytoma and Paraganglioma
2.3.3 Metastases to the Adrenal Glands
2.4 Adrenal Incidentaloma
2.5 Partial Adrenalectomy
References
3: Open Versus Minimally Invasive Approach
3.1 Introduction
3.2 Validation of Laparoscopic Adrenal Surgery
3.3 Still a Place for Open
3.4 Open Surgery
3.4.1 Current Indications
3.4.2 Risk of Conversion to Open
3.5 Open Technique
3.5.1 Anterior Approach
3.5.1.1 Technique for the Right Side
3.5.1.2 Technique for the Left Side
3.5.2 Posterior Approach
3.5.3 Thoracoabdominal Approach
3.6 Conclusion
References
4: Retroperitoneoscopic Versus Laparoscopic Adrenalectomy
4.1 Background and Clinical Considerations
4.2 Intraoperative Outcomes
4.3 Postoperative Outcomes
References
5: Retroperitoneoscopic Approach in Malignant Disease
5.1 Introduction
5.2 Preoperative Evaluation of Patients with Adrenal Lesions Suspicious for Malignancy
5.3 Minimally Invasive Adrenal Surgery for Indeterminate Adrenal Nodules Suspicious for Malignancy
5.4 Minimally Invasive Adrenal Surgery for Metastatic Disease
5.5 Minimally Invasive Adrenal Surgery for Adrenocortical Carcinoma
References
6: Anesthesia in Posterior Retroperitoneoscopic Approach
6.1 Introduction
6.2 Preoperative Patient Evaluation
6.3 Anesthesia for PRA
6.4 Postoperative Pain Management
References
7: Technical Steps of Posterior Retroperitoneoscopic Adrenalectomy
7.1 Introduction
7.2 Surgical Instruments and Operation Table Setup
7.3 Surgical Team
7.4 Step-by-Step
7.4.1 Positioning the Patient
7.4.2 Placing the First Trocars (Balloon Trocar and Lateral Trocar)
7.4.3 Creating the Working Space
7.4.4 Placing the Third Trocar (Medial Trocar)
7.4.5 Finding Upper Pole of the Kidney
7.4.6 Finding the Inferior Vena Cava (IVC)
7.4.7 Dissecting and Ligating the Adrenal Vein
7.4.8 Dissecting the Entire Gland
7.4.9 Retrieving with an Extraction Bag
7.4.10 Final Check (Hemostasis) and Closure
7.5 Tips and Tricks
7.6 Video of Posterior Retroperitoneoscopic Adrenalectomy
7.7 Postoperative Care
7.8 Final Notes
References
8: Intraoperative Complications
8.1 Introduction
8.2 Vascular Injury, Hemorrhage, and Cardiovascular Complications
8.3 Retroperitoneal Fatty Tissue
8.4 Injuries of the Intestine
8.5 Injuries to Other Organs
8.6 Abdominal Wall Relaxation and Hypoesthesia
8.7 Pleural Lesions
8.8 Misplacement of Trocars
8.9 Rare Complications
8.10 Risk Factors for Intraoperative Complications
8.11 Laparoscopic Versus Retroperitoneoscopic Adrenalectomy
References
9: Management of Vascular Injuries (IVC)
9.1 Introduction
9.2 The Major Vascular Complication
9.3 Surgical Team and Operation Room Staff Preparation
9.4 Vascular Injury Repair
9.4.1 How to Do It?
9.5 Vascular Injuries and Learning Curve
9.6 Case Report
References
10: Converting to Open Surgery
10.1 Introduction
10.2 Definition of Conversion to Open Surgery
10.3 Risk Factors Associated with Conversion to Open Surgery during Transperitoneal Laparoscopic Adrenalectomy
10.3.1 Obesity
10.3.2 Size of the Tumor
10.3.3 Pheochromocytoma
10.4 How to Convert?
10.4.1 Choice of Incision
10.4.2 Open Right Adrenalectomy
10.4.3 Open Left Adrenalectomy
10.5 Concluding Remarks
References
11: Final Outcomes
11.1 Introduction
11.2 Operative Time
11.3 Complication Rate and Mortality
11.4 Conversion Rate and Blood Loss
11.5 Postoperative Pain
11.6 In-Hospital Days and Recovery to Normal Activity
11.7 Learning Curve
11.8 Final Notes
References
12: Robotic Surgery and Innovation
12.1 Introduction
12.2 Surgical Technique of Robotic Posterior Retroperitoneal Adrenalectomy
12.3 Preoperative Preparation and Setup of the Patient
12.4 Evidence Regarding Robotic Posterior Retroperitoneal Adrenalectomy
12.4.1 Case Series
12.4.2 Laparoscopic Versus Robotic Posterior Retroperitoneal Adrenalectomy
12.4.3 Robotic Posterior Retroperitoneal Adrenalectomy Versus Transabdominal Lateral Robotic Adrenalectomy
12.4.4 Cost Analysis
References