Robot-Assisted Total and Partial Adrenalectomy



Fig. 5.1
(a, b) The operative setup. The robot is docked over the shoulder of the patient at a 45° angle with the long axis of the operating table. The bedside assistant and scrub technician are on the opposite side of the patient



The surgical team includes a minimum of one operating console surgeon, one bedside assistant, an anesthesiologist, a scrub technician, and a circulator. The operating surgeon may scrub initially to assist in patient preparation and trocar placement, and then breaks scrub prior to sitting at the robotic console. The bedside team remains scrubbed throughout the case and assists the console surgeon during the procedure.



Patient Positioning


General endotracheal anesthesia is used for this procedure. A urethral catheter is placed before positioning the patient. The patient is placed in the full flank position with an axillary roll. Moderate table flexion (approximately 15°) is used to increase the space for trocars with the kidney placed at the center of the table break (Fig. 5.2). The arms are padded at the elbows, wrists, and hands, and extended in front of the patient with the upper arm suspended. Alternatively, the upper arm may be tucked behind the patient, rolled in a sheet over foam pads or blankets. The advantage of this position is that the patient’s upper arm is less likely to inhibit movement of the cephalad robotic arm . However, care must be taken to prevent over extension of the shoulder, which may precipitate a neuropraxia. The lower leg is flexed, the upper leg is straight, and all lower extremity pressure points are padded. The patient is secured to the table at the chest, iliac crest, and knees with wide cloth tape and Velcro straps to ensure the patient does not move during the procedure. Tape blisters are avoided by placing foam padding or abdominal pads between the skin and the tape. All pressure points including the head, neck, axilla, arms, hip, knees, and ankles are inspected and additional padding is placed if necessary. Security of patient positioning is confirmed prior to draping by “airplaning” the table to expose the patient’s abdomen. This is the table position used to close the trocar wounds at the end of the procedure and also to convert to an open procedure in an emergency.

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Fig. 5.2
(a, b) Patient positioning. The patient is placed in the full flank position with an axillary roll. The upper arm can be secured behind the hip at the patient’s side if it is felt that outward extension might cause collisions with the robotic arms. The lower leg is flexed and the upper leg is straight. The table is flexed approximately 15°. All pressure points are protected. The patient is secured to the table at the chest, hips, and knees with wide cloth tape over foam pads, and Velcro straps


Trocar Configuration


The trocar configuration for left and right robot-assisted adrenalectomy is demonstrated in Fig. 5.3a, b, respectively. Two 12 mm standard trocars and two 8 mm robotic trocars are used for both techniques. An additional 5 mm trocar is used for a right-sided technique for retraction of the liver. Table 5.1 includes an instrumentation list.

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Fig. 5.3
Trocar configuration. The midline and lateral border of the ipsilateral rectus abdominis are marked prior to insufflation. The isilateral costal margin and anterior superior iliac spine are marked after insufflation. The trocars are placed as shown. AAL anterior axillary line, MCL midclavicular line, C camera trocar, A 12 mm assistant trocar, R1,R2 8 mm robotic trocars, UMB umbilicus



Table 5.1
Instrumentation list
































Surgeon instrumentation
Assistant instrumentation

Arm 1—Right

Arm 2—Left

Arm 3 (usually unnecessary)

• Suction-Irrigator

• Curved monopolar scissors
• Maryland bipolar grasper
Prograsp dissector
• Blunt tip grasper

• Monopolar hook
• Laparoscopic needle driver

• Robotic hem-o-lok applier
• Laparoscopic scissors

• Hem-o-lok or titanium clip applier

• 10 mm specimen bag


Surgical Anatomy


Knowledge of the surgical anatomy of the adrenal gland and the vessels associated with each gland is essential to performing a successful adrenalectomy. Each adrenal is associated with a major vessel and has a unique venous drainage. The adrenal gland receives its arterial blood supply from the branches of the inferior phrenic artery, renal artery, and aorta. This network of arteries enter the gland along its superior and medial border making the inferolateral, posterior, and anterior surfaces of the gland relatively avascular.

The right adrenal gland is in close relationship with the inferior vena cava (IVC) . The right adrenal vein arises from the superomedial surface of the gland and drains into the IVC. The left adrenal vein leaves the adrenal gland via the inferior aspect and drains into the left renal vein. It is easiest to identify the left adrenal vein along the superior border of the left renal vein and medial in location as compared to the insertion of the left gonadal vein.

Note that under robotic visualization, the right adrenal vein runs for a few millimeters on the anterior surface of the adrenal gland before entering it. This gives enough room to doubly ligate the vein or place multiple clips. Additionally, there may be collateral veins draining from the adrenal gland. These veins are distinguishable from the adrenal vein in being more tortuous, thin walled, and inferior than the main adrenal vein. The main adrenal vein is high up on the adrenal, has thicker walls, and is shorter.


Step-by-Step Technique (Video 5.1)



Transperitoneal Left Robot-Assisted Adrenalectomy



Step 1: Trocar Placement

Abdominal insufflation is achieved using Veress needle introduced at the level of the umbilicus in the left lateral abdomen, below the costal margin. Insufflation is initiated at 20 mmHg but may be decreased to 15 mmHg during the operation. The midline is marked from the xiphoid to the umbilicus with a marking pen. The lateral border of the ipsilateral rectus abdominis is also marked. A mark for the left robotic trocar is placed on this line, approximately two finger-breadths below the costal margin. A mark for the camera trocar is placed one hands-breadth below and shifted laterally to improve triangulation and focus on the adrenal. The 12 mm camera trocar is placed first and the robotic camera is introduced. Next, the two 8 mm robotic trocars are placed at their previously marked sites, under direct vision . Finally, a 12 mm assistant trocar is placed in the midline, immediately superior to the umbilicus (Fig. 5.3).


Step 2: Mobilization of Colon and Spleen

We use a 0° camera with the Maryland bipolar forceps in the left arm and a monopolar hook or scissors in the right arm (electrocautery settings: 40 W bipolar, 40 W monopolar). The splenic flexure is mobilized along a line between the colon and the line of Toldt. Lienophrenic, lienorenal, and lienocolic ligaments may be taken down to allow the spleen along with the descending colon to fall medially and out of the operating field (Fig. 5.4). This helps to provide optimal exposure of the left adrenal gland.

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Fig. 5.4
Take down of the lienocolic ligaments (a) and lienorenal ligaments (b) to free the spleen and expose the left adrenal gland


Step 3: Exposure and Ligation of Left Adrenal Vein

Gerota’s fascia is incised at the level of the renal hilum and the left renal vein is identified. The left adrenal vein is identified draining from the inferomedial aspect of the gland into the superior border of the renal vein (Fig. 5.5). The left adrenal vein is isolated circumferentially using robotic instruments (Fig. 5.6). The adrenal vein should be ligated prior to manipulation of the adrenal gland , particularly in cases of pheochromocytoma in which there is potential for release of catecholamines into the systemic circulation during manipulation of the tumor resulting in sudden hypertension. The adrenal vein is ligated using Hem-o-lok® or titanium clips placed by the assistant, or by using robotic Hem-o-lok clips , (Fig. 5.7). The vein should have enough length to be doubly ligated.

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Fig. 5.5
Exposure of left renal vein and adrenal vein


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Fig. 5.6
Circumferential robotic dissection of left adrenal vein


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Fig. 5.7
Ligation of left adrenal vein using clips or suture ligation


Step 4: Dissection of Pancreas Away from Gerota’s Fascia

To prevent pancreatic injury, care must be taken during dissection in the plane between the pancreas and Gerota’s fascia . Once the plane is identified, it is extended cephalad towards the lienophrenic ligament. The splenic artery and vein are frequently encountered during this dissection and their tortuous course should be noted to avoid injury. Most of the dissection is carried out with the right robotic instrument (hook or scissors), while the shaft of the left robotic instrument (Maryland forceps ) is used to retract the pancreas and splenic vessels. The wrist of the Maryland forceps can be angled in such a way so that the instrument can still be used for dissection whilst providing atraumatic retraction of the pancreas.


Step 5: Dissection of Upper Pole Renal Attachments

After the adrenal vein is secured and the pancreas has been dissected away from Gerota’s fascia , gentle traction on the adrenal gland using the Maryland bipolar forceps and counter traction on the kidney by the assistant aids in the dissection of the gland by opening the space between the adrenal gland and the upper pole of the kidney (Fig. 5.8). Dissection is carried out along the capsule of the upper pole of the kidney as this plane is generally avascular and as well achieves a wide tissue margin around the adrenal tumor. The magnification provided by the robotic camera generally allows for identification of small adrenal arteries, which can be clipped or coagulated. Collateral veins may be seen exiting the adrenal gland. These thin walled veins may be either ligated with clips or cauterized.

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Fig. 5.8
Dissecting the plane between the left adrenal gland (left) and the upper pole of the kidney (right) following ligation of adrenal vein


Step 6: Dissection of Medial, Lateral, and Superior Attachments

Careful, meticulous dissection of the adrenal gland while avoiding grasping the gland directly can help minimize blood loss. Medially, there will be small arterial branches from the aorta, and these can be controlled with clips or electrocautery to help minimize blood loss . The remaining superior and lateral attachments of the gland are dissected free (Fig. 5.9).

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Fig. 5.9
Transecting final superior adrenal attachments to free the left adrenal gland


Step 7: Entrapment and Extraction of Specimen

The adrenal gland is placed in a 10 mm specimen entrapment bag (Fig. 5.10). Pneumoperitoneum is decreased to 5 mmHg and the adrenal bed is inspected for bleeding. Hemostatic agents such as Floseal or Surgicel may be used to assist hemostasis with electrocautery. After adequate hemostasis is confirmed the specimen bag is removed by extending the midline 12 mm assistant trocar.
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Jul 17, 2017 | Posted by in UROLOGY | Comments Off on Robot-Assisted Total and Partial Adrenalectomy

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