Category: Laparoscopic/ Robotic: Adrenal

VS17-5 - Laparoscopic adrenalectomy: surgical technique, tips and tricks.

Sun, Sep 23
2:00 PM - 4:00 PM

Introduction & Objective :

Laparoscopic adrenalectomy(LA) has rapidly consolidated as the standard approach for surgical removal of the adrenal gland, since the initial report by Gagner.
The objective is to present an instructional video about laparoscopic adrenalectomy, providing tips and tricks.

Methods :

We use different video clips of various right and left operations to show the main steps of the laparoscopic approach and the main difficulties that may arise during surgery.

The case of left adrenalectomy was a patient with suspected pheochromocytoma which was confirmed on final pathology. The right adrenalectomy was a patient with a large adrenal mass. Differential diagnosis included the possibility of adrenal carcinoma (potential contraindication for laparoscopic approach), but the final pathologic diagnosis was myelolipoma.

Results :

In case of left LA key points to this surgical technique are:

1.  Exposition:We perform an ample opening of the parietal peritoneum along the line of Toldt mobilizing the left colon and dislocate the spleen medially, exposing the diaphragm, the adrenal area and the renal pedicle.

2.  We start dissecting the adrenal gland from an easy site avoiding manipulation of the mass. If the patient is slender and the identification of the adrenal vein is easy, clipping and transection is the first step of procedure. However, first ligation of the adrenal vein may cause congestion of the adrenal gland which makes difficult pathological examination. First-step transection of the adrenal vein is not strongly recommended for left adrenalectomy.

The landmarks for the right LA are: the quadrate lumbar muscle, psoas muscle, inferior vena cava(IVC), and diaphragm. Keypoints:

1.  Exposition: In a slender patient, it is easier to identify the IVC. In that case, we can expose IVC first, and divide the fat between the adrenal gland and upper pole of the kidney, including the inferior and posterior adrenal vessels. In more obese patients, perirenal fat covers the IVC making its identification more cumbersome.

2.  After decreasing the blood flow to the adrenal gland by cutting the inferior, posterior, and middle adrenal arteries, we can clip and cut the adrenal vein. Then, it is possible dissect the adrenal gland upwards. A regular sealing device can safely divide the upper vessels

It is very important for the surgeon to remove the tumor and surrounding fat en bloc, especially in the case of large or irregular tumors because of the potential for malignancy.

Conclusions : Laparoscopic adrenalectomy is a safe and effective treatment for adrenal disorders, with a systematic procedure easy to reproduce for urologists who start using the laparoscopic technique.

Gema Del Pozo Jiménez

Staff Urologist
University Hospital Puerta de Hierro, Majadahonda.
Madrid, Madrid, Spain

- 2003-2009: Doctor of Medicine and Surgery (MD). University of Alcalá, Madrid, with a final grade of Honours.
- 2010-2015: Urology Residency. General University Hospital Gregorio Marañón, Madrid.
- 2013-2017: Degree in Design and Statistics in Health Sciences. Autonoma University of Barcelona.
- November, 2014: European Board of Urology (EBU) Online Written Examination. Madrid.
- June, 2015: European Board of Urology (EBU) Oral Examination. Brussels.
- 2013-2017: PhD. Complutense University of Madrid with mention of "Cum laude" with the title: Predictive model of mortality in patients with transitional bladder cancer treated with radical cystectomy.
- October 2017: Enrollment in the Master in Health Research Methodology. Autonoma University of Barcelona.
- January-May 2018: University Title of Expert in Urooncology of the Autonoma University of Madrid,
- Currently working as FEA of Urology since June 2015 in Puerta de Hierro University Hospital (Majadahonda), as well as a private activity in H.U. La Zarzuela and H. University H.M. Torrelodones.
• Practical teaching in the subject of Urology of the Autonoma University of Madrid in H.U.Puerta de Hierro (2015-2018).
• Online teaching as a professor in the course of laparoscopic and robotic radical cystectomy (1st Edition) of the European School of Urological Laparoscopy (2018).
3.-PUBLICATIONS IN JOURNALS: Five publications as author, four publications as co-author (three in Spanish Archives of Urology and one chapter of the Urology Resident's Book (Internet)) and four abstracts of European and world congresses, three as author and one as co-author (European Urology Supplements and Journal of Endourology).
4- COMMUNICATIONS PRESENTED AT NATIONAL CONGRESS: As author 32 papers: Eighteen papers and as co-author 36 co-author papers.
5- SUBMITTED VIDEOS IN CONGRESS: 14 videos as author and 6 videos as co-author.
6-COMMUNICATIONS/VIDEOS PRESENTED AT INTERNATIONAL CONGRESS: As author (9 presentations) and as co-author (4 presentations).

Ignacio T. Castillón Vela

Staff urologist
H.U. Puerta de Hierro. Majadahonda
Villaviciosa de Odón, Madrid, Spain

Consultant Urologist. Department of Urology.
Hospital Universitario Puerta de Hierro Majadahonda
H.U. Madrid Torrelodones.
Escuela Europea de Laparoscopia Urológica. Madrid

1984-1990 Doctor of Medicine. Universidad Autónoma de Madrid
1992-1997 Urology Residency. Department of Urology. Fundación Jiménez Díaz. Madrid.
1998. Certificate. Educational Comission for Foreign Medical Graduates (ECFMG).
2/1999- 1/2001 Clinical Fellow in Kidney and Pancreas Tansplantation
National Institute of Transplantation - St Vincent Medical Center. Departament of Urology. University of Southern California (USC). Los Ángeles, California. EEUU.
2001 PhD in Medicine and Surgery. Universidad Autónoma de Madrid.
2005-2006 Master in Medical Direction and Clinical Management Universidad Nacional de Educación a Distancia (UNED)
2008 University Expert Certificate in “E learning 2.0: Internet Education and On line training". Universidad Nacional de Educación a Distancia (UNED)
2009 Accreditation as Da Vinci Robot Console Surgeon.

Editor of 4 Books
Author in 5 chapters in urological Books
Editor/Author of 9 Audiovisual Projects
27 Articles in indexed Journals
85 Panel Presentations in Urological Meetings
114 Podium/Poster/Video presentations at urological meetings.

Reviewer for the following Journals:
- Archivos Españoles de Urología
- Urology
- Journal of Endourology
Reviewer for the selection commitee:
- Spanish AEU Annual Meeting
- European Association of Urology (EAU) Annual Meeting

Jorge Turo-Antona

University Hospital Puerta de Hierro, Majadahonda.
Madrid, Madrid, Spain

Jorge Turo Antona
Especialista en Urología
Facultativo Especialista en el Servicio de Urología del Hospital Universitario Puerta de Hierro de Majadahonda (Madrid)

Diego Rengifo-Abbad

University Hospital Puerta de Hierro, Majadahonda.
Madrid, Madrid, Spain

Javier Sáenz-Medina

University Hospital Puerta de Hierro, Majadahonda.
Madrid, Madrid, Spain

Maria Rodriguez-Monsalve Herrero

University Hospital Puerta de Hierro, Majadahonda.
Majadahonda, Madrid, Spain

Joaquin Carballido-Rodríguez

University Hospital Puerta de Hierro, Majadahonda.
Madrid, Madrid, Spain