Robotic Redo Adrenalectomy

Abstract

Introduction:

Despite current studies that demonstrate nonsuperiority over laparoscopy, the robotic platform for adrenalectomy has become increasingly popular.¹ The benefits of the robot-assisted technique include superior depth perception, greater degrees of movement, increased comfort because of ergonomic design, and improved magnification and resolution to enhance vision.² These advantages are invaluable when facing dense adhesions, loss of landmarks, and ambiguous tissue planes characteristic of reoperative surgery. This video describes the case of a 78-year-old man who had a recurrent left adrenal mass and underwent robotic redo adrenalectomy.

Materials and Methods:

The patient presented with history of a left adrenalectomy for a nonfunctioning left adrenal mass 8 years ago. The pathology from the index operation reported an adrenal adenoma. During follow-up, a recurrent 5 cm left adrenal mass was ascertained. Biopsy showed that the mass was consistent with adrenal tissue, likely because of incomplete resection. Owing to the size and recurrent nature of the lesion, a robotic left completion adrenalectomy was scheduled. The patient was positioned in a right lateral decubitus position with the robot positioned posteriorly. One assistant and three robotic ports were placed. After establishing a pneumoperitoneum, diagnostic evaluation did not discern any evidence of carcinomatosis. The splenocolic ligament had been divided previously so attention was focused initially on the adhesions along the splenorenal ligament. These adhesions were divided and the adrenal mass was identified. The adrenal mass was dissected from its attachments to the spleen, tail of the pancreas, and superior pole of the kidney. The native left adrenal vein was then clipped and ligated, and the mass was elevated from the retroperitoneum. The vessel sealer was used to complete the dissection and the mass was removed from the abdomen.

Results:

The patient had an uncomplicated postoperative course and was discharged home on postoperative day 1. Final pathology returned as an adrenal cortical carcinoma. The patient was referred to oncology and is being considered for mitotane treatment.

Conclusion:

The robotic platform facilitated a meticulous retroperitoneal dissection in a technically challenging reoperative case. Key technical points of the case include defining the plane at the former splenorenal ligament, careful dissection of the spleen and tail of the pancreas to delineate the adrenal mass, and identification of the left renal vein, which can be followed to the left adrenal vein. Adequate medial dissection is critical to ensuring a complete resection of the adrenal gland.

Acknowledgment:

Funding for this study was provided by the Center for Advanced Surgical Technology at the University of Nebraska Medical Center.

No competing financial interests exist.

Runtime of video: 9 mins 24 secs