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Laparoscopic Urology- Lap Adrenalectomy

Nov 23 | 1:30 PM

Laparoscopic surgery is a minimally invasive surgical procedure that has become popular in recent years. Since its original description in 1992, laparoscopic adrenalectomy has been the gold standard for surgical treatment of most adrenal disorders. As this approach becomes more extensively employed, critical steps of the technique must be maintained to ensure intended outcomes and success. Join us as we gather some brilliant insights from Dr. Vijay Radhakrishnan.

[Music] uh good evening everyone uh welcome to netflix i am dr naveda and on behalf of netflix i welcome you all to today's session uh today we have with us uh dr vijay uh dr vijay radhakrishnan a senior consultant uh urology from martilla medici uh palais i'll start your presentation sir uh good evening everybody um i first of all let me thank um uh the netflix team and uh nivedita and dr samantha uh for giving me this opportunity uh to share my experience with laparoscopy neurology i come from kerala and i work in this institute it's two years old mars liba medicity it's in the central part of kerala and it's a 650 bed multispeciality hospital and we do all advanced uh neurological procedures in this center as most of you are aware laparoscopy or minimally invasive surgery is the need of the day and people actually come to your opd asking for laparoscopic surgery because it has a lot of advantages uh traditionally surgery uh was done any surgery surgery urology any surgery was done by open techniques wherein it involves a big incision you need to cut the muscles and then it leaves a bad scar he's got significant pain the recovery is much slower but uh probably in the last 20 30 years laparoscopy has changed all this and much more beneficial to the patients their recovery is much more easier with less car less pain also for the surgeon it gets much to the um now the the smooth recovery of the patient in neurology the last 20 years has seen tremendous development in laparoscopy and has come up to the stage of 3d laparoscopy wherein gives much much more clarity and much more depth perception so we use a lot of 3d mechanism in 3d technology for doing all our laparoscopy cases um with all these uh with the introduction i like to stress on lap adrenalectomy is one common topic even um general surgeons and onco surgeons gastro surgeons are interested in uh um uh hearing so i like i like to show a couple of videos and the techniques that we use to do a laparoscopic adrenalectomy basically any surgery which surgeon is able to complete by a laparoscopy becomes the indication and which is beyond the skill and experience or the depending on that difficulty of the case becomes a contraindication so in in adrenal ectomy this has become the standard of care since uh in the last 10 20 years and now it's possible to do most of the cases uh laparoscopically uh in fact i personally feel uh laparoscopic surgery for adelectomy is much more easier than an open surgery because it's a small gland sitting on the upper pore of the kidney on either side and to reach this gland it needs a large incision and to search for such a small gland in that retroperitoneum is much more easier laparoscopically than by open surgery so definitely it's become the standard of care but still there could be some contraindications most of them are relative contraindications there aren't any absolute contraindications as i said it's only depending on the the skill and the experience of the surgeon still the absolute contraindication could be a locally uh local reference of a previously resected adrenal mass or it's an invasive adrenocortical carcinoma with involvement of the adjacent the organs uh there are critical organs all around the abdominal gland uh the liver the kidney below the ivc inferior vena cava uh on the medial side or if the patient is un unfit for gen laparoscopic surgery because of some severe cardiopulmonary disease where the patient cannot tolerate uh the pneumoperitoneum for that uh long duration otherwise there aren't um any absolute contraindications uh for laparoscopic the anatomy the surgical anatomy is the crucial part in any laparoscopic surgery not just for adrenalectomy you need to know the anatomy you need to know uh the the location and the the blood vessels the blood supply of that particular organ in the detail uh to make the dissection much more easier when you go laparoscopically there is a slight uh difference in the anatomy and the blood supply of the right and the left adrenal gland both of them are located uh comfortably on the superior pole of uh the kidneys on either side uh the the one of the major differences um the the location of the right antenna extremely close to the inferior vena cava on the under surface of the liver it's hidden in that uh in that groove between the uh kidney liver and the inferior vena cava um the left as little it's a little more spacious uh beneath the spleen and between the spleen and the and the uh the upper pole of the left kidney the blood supply now uh because um it's located in such a crucial junction the arterial supply are is mainly through different small uh by uh different small to exact coming from the surrounding vessels there is no single large vessel supplying uh either of the adrenal gland it could come from the superior vesicle superior directly from the iota directly from the inferior vena infraphrenic artery or it could come from the um the renal artery uh so it could multiple small tweaks supply both of the uh both the adrenal glands the venous drainage is much more defined usually a single vein on either side drains both the adrenal gland and on the left side drains into the inferior into the renal vein and on the right side it's that is the crucial step in the right side wherein a small vein drains um into the inferior vena cava directly uh located in that groove between the liver and the inferior vena cava so that if you know this anatomy the dissection and the control of the vessels becomes much more easier i would like to show two cases wherein ah one on right side this case is a right side young child ah with an incidentally detected right suprarenal lesion it's a non-functional a non-functioning adrenal gland it was picked up on an ultrasound done for some big discomfort and it was about two uh two centimeter um on an ultrasound and um and ct confirmed that close to two point five two point seven centimeter lesion in the uh right suprabeneal region and then pet ct confirmed an fpg avid uh moderately enhancing mass so that made the surgery an essential one so this was the ct where you can see a small adrenal gland located on top of the um on the top of the upper pole of the kidney and just beneath the liver close to the midline on the side of ivc so we have like our technique of pore placement and so the patient is placed in lateral position the most of the renal surgeries upper track renal surgeries and adrenal surgeries we do it in lateral position um and on on your on your right side you can see the head and the foot end we use for the right side we use a 10mm port that is a camera port this being a child the other ports are all three mm ports we need two working ports on either side uh on the right and left uh working ports one laterally which is a retraction port one 3mm below that is to retract the liver this is the standard pores for most of the uh right sided upper track surgeries uh but in others we may use larger pores 5 and 10 mm this being a child we are going in for uh three mm ports uh can we have the video please so uh once we are in uh we'll just start dissecting actually right side uh the the adrenal gland it's it's very easily seen on your right side you can see the uh on the upper hand you can see the liver and then we use this uh machine i can just pause one minute yeah so we use this instrument that on the right side we use this instrument uh with suction hook and irrigation all three in one combined uh instrument which the hook comes out and you can connect the caudary to that that helps us in dissecting the planes and uh so now you can see uh the address swelling there the liver on the right side the bowel is just coming on that lower part of the screen and on to the on the left side is the upper pole of the kidney that blue is structured down there uh probably is the ivc so as we will be clearer as and when we go on dissecting so that that hook suction hook helps in lot uh is easily uh helps in the dissection where you can just use the hook to dissect and then if there's any oozing you can just suck along with that and then cauterize with the uh hook actually at the same time so that makes our life much easier can you just play the video yeah so now the dissection continues that is the upper upper part of the liver separated from the liver not much of adhesions clear planes the left hand gives adequate traction so that uh it is easier to dissect now this flimsy tissue all around that place where the dissection is there that there will be the uh the adrenal vein i said as i said earlier there is no single vessel which is there so most of them will come in this uh artery so you just keep dissecting all around with adequate traction with your left hand and then keep uh sitting now the posterior wall is seen can you just pause a little bit one minute yeah now what is clip that that is the that is the vein which i told that drains from the adrenal gland directly to the ivc right beneath the liver that that that is a crucial part where if you can get getting hold of this vein or in the right side is the most crucial part of adrenal ectomy so the basic thing is go on dissecting all around and that is the posterior abdomen involved that reddish the muscles which are seen so basic thing is go on dissecting all around most of the arterial twigs will come in that dissection in others we can use a harmonic scalpel to get or get clear all the uh the arterial tricks uh this we could manage with a hook suction suction and now uh we just clip the arduino bin can we just restart the video yeah now we're just clipping that adrenal vein just make sure it doubly clipped it and then just with a harmonic scalpel which is dividing that's dividing the vessel that is the last part of the uh this thing and just from flimsy tissue and that is over that is a specimen ah it is placed inside a plastic bag and it is uh retrieved through the fire the 10 mm um camera code which is placed in a small drain for a day uh the recovery is extremely um uh the recovery is usually uh within 24 to 48 hours we start early the next day itself uh the drain catheters everything out the next day and usually discharge on the second or the third day uh no scar and no very minimal pain and and we can finish it up open surgery this would have taken at least um one uh one one and a half hours we need to open up all the muscles and then go retro but only and find this mostly it's much more difficult to open surgery and lapis could finish just in about 20 30 minutes so this is about the right side now you go to the left side left left-sided adrenaline this is an adult patient and uh about i think i think a 50 year old lady she came with a vague pain on the on the left side and an ultrasound there was this mass lesion which was seen in the right and the left atrium area uh compressing the kidney displacing the left kidney downwards a ct confirmed that about seven or eight centimeter tumor um on the in the left uh the left side uh which required a uh left adrenalectomy so uh on the left side uh this being an adult uh we usually go for three 10mm ports uh the camera port and the two working ports five or ten mn one retraction port and uh we don't need the obviously the liver attraction on this side uh can we just play the video yeah so this is the left side we can use our harmonic scalpel now here we need to uh move this planic flexure of the colon which will come in the way then now that is a splenic flexure this is the swelling which is coming in the in the picture this plane is just retracted with the left hand and that ah plane between the spleen and the uh that left side uh adrenal is dissected this planning fracture needs to be that is that is playing fletcher and the descending colon uh which is just uh moved away now the swelling comes into a picture that is the tail of pancreas uh which is also moved immediately the tumors dissected all around and now the anatomy becomes little more clear that is the uh that is the upper pore and then you separate it from the um in the upper pole of the uh kidney as well now that is the upper being separated from the uh upper pole of kidney and now we come to the medial portion there you need to be a little more careful you will have uh neovascularizations and uh the vein will come there in that region uh so our main aim is to dissect all around uh because most of the arterial twigs will go in there and this retractor to the lateral cord will help us in uh dissecting this being um a malignant tumor they were much more vascularity around the adrenal which is usually not seen in a usual adrenal swelling so uh one by one we were just clipping the vessels you just clip the vessels and then they use a harmonic scalpel to divide it yeah so that secures the vessel and down to the specimen side you can just uh uh dissect uh now these arterial twigs and the main trunk has to be uh divided first and now we're going towards the main adrenal vein there you can see the main adrenal vein coming into a picture and it is draining going down and beneath uh to the uh left uh renal vein is joining the left venal vein but then before clipping that we have to make sure that there is no other arterial twigs in between so we need to clear off the tissues in um in that plane uh most of the smaller twigs will come with this harmonic scalpel but uh clip the abdominal vein we have to make sure that we have disconnected all the arterial twigs so this being um adrenocortical carcinoma uh we had to uh uh we we usually don't find so many vascularity around the adrenal gland um but here is that it was different and we had to secure that and then divide each one of them before clipping the uh adrenal vein so now it's dissected all around that little vein is nicely seen and as you as you hold the adrenal vein you can see most of the it's almost collapsed that itself is an indication that we have secured all the arterial twigs but still we have to make sure otherwise they can be some losing all around and can make the the field are quite messy so now we are sure that there are no more vessels and it's dissected all around so we can safely clip the adrenal vein and just divide that and most of the procedure is over so we just um clip the adrenal vein and cut it in between and some tissue will be connect connecting it to the uh retroperitoneum and that that finishes off the surgery so yeah it's just some issue there remaining once we get that it's that that that ends the procedure yeah so this was quite a big swelling about seven or eight centimeter and it came out to be adenocortical carcinoma but this is a complete uh excision of that yeah so that that completes the adrenalectomy you can just inspect the fosa again so you can see a couple of tweaks there and the main renal adrenal vein and you can just place in a drain put the swelling in a in an endo pack and you can retrieve it through one of the 10 mm pores so that completes the uh the left sided adrenectomy so as i said it's basically a need to know uh the anatomy properly and then just go on dissecting some gadgets can definitely help we use a lot of 3d laparoscopy as i said it really helps in the depth perception uh for beginners it's it's it's it's extremely useful a lot of reconsider urology has a lot of reconstructive uh work uh for piloplasties and inverse suturing uh fine suturing uh so 3d in that cases are really uh is helpful and most of the cases these days in neurology can be completed laparoscopically and definitely adrenectomy is one of the uh surgeries which can be done it depends on the skill and the experience of the surgeon and as i said 3d laparoscopy uh definitely adds a advantage to that and it's definitely the standard of care in um [Music] thank you thank you so much for that session we have dr vishnu i'm accepting you up on stage uh please turn on your audio video when prompted good evening hi sir i want to ask that what is malignant fields chromocytoma will you please elaborate as well sir i know about the malignant tumor you know yeah if your cytomy is a it's a functional swelling of the adrenal gland but it secretes a lot of hormones which raises the blood pressure of the patient in that when there is it can be benign or malignancy malignant is a cancerous tumor with the few chromosomes which is cancerous is a malignant thiochromocytoma the uncontrolled cell it it raises the blood pressure to a great extent and you need two or three medications to control the blood pressure as well as excision of the tumor becomes essential not only to control the uh blood pressure but also to because it's a malignant swelling thank you sir there are a lot of comments that say that they've enjoyed the session yeah i was just reading that yeah somebody has asked this german uh that has got nothing to do with the adrenal gland uh it's it's one of the reproductive organs which is involved the poor positions that's what i said um dr kumar has asked for the both positions as i said i i showed in that slide actually for all renal upper track surgeries adrenal renal surgeries we place the patient in lateral position full lateral position and place closer to our side of the table and you keep strapped and then the camera port that is you a that is a compulsory 10 mm port because we cannot have a smaller port there so the camera put is a 10 mm port which we usually place it on an averagely built patient we place it fourth finger laterally as well as fourth finger cranially to the umbilicus that is that will come in the pararectal uh position actually this i'm seeing in an averagely built patient athena patient you may have to come medially and caudally and in a fat in an obese patient you'll have to go more laterally and cranially so on an averagely built patient four finger breath lateral and cranial to the umbilicus is the first hole depending on that based on that the other ports are placed in others we use three 10 mm and one 5 mm port uh periodic it come down to 3m port the second on i'll tell you about the right side the second the right hand port right working port is usually placed almost in line with the first uh port a little laterally right at the inferior margin of the uh cost inferior border of the costly margin that is your right working pole the left working port is again mostly for 10 mm but sometimes 5 mm ah that is placed at the midline of the anterior superior lx spine and the spinal umbilical line so you place it at the midpoint of the spinal umbilical line that is again a 10 mm ah the fourth the fourth port is usually a pi mm that is a retraction port where which i showed on the left side use a retraction to retract the kidney or the adrenal swelling that is usually a 5 mm that you can place it depending on that position of the swelling if it's a renal one you need to come a little down for adrenal you can just go a little above that is at your convenience where you want to retract and in the right side one extra port to retract the liver that is in the midline below the zippy sternum you need to put in a 5 mm so that you can ah retract the liver from the field so that the abdominal and the renal uh area becomes clear it's very similar on the left side except for the liver there are quite a few questions that have come in um i'll just take them so i think chances of damage to the spleen or splenic flexure yeah that is there in any surgery not only to adrenal adrenalectomy obviously you need to dissect carefully exactly that is why i said knowing the anatomy is extremely important uh and as you keep doing um you know exactly where the structures are and definitely if you careful enough you can avoid but otherwise there is definitely a chance but i haven't encountered i encountered any injury to the splenic vessels but i've seen damage to the splenic vessel but i've seen damage to the or injury to the splenic flexure of the column but then that was identified and repaired in the same city sometimes um the harmonic scalpel which we use uh the harmonic scalpel can generate uh it usually it's a very high temperature especially the non-insulated blade uh inadvertently if you just touch that to the bowel that can cause ischemic injury that may not be noticed in drop that will be evident uh maybe third or fourth day and you may find a necrotic sloughing of the colon there and a leak from there so that is dangerous so these things you learn and then you have to avoid it that is the only thing there is a risk to damage risk of damage to the adjacent organs in any surgery that has to be dealt with carefully um then any complications you frequently encounter encounter with this procedure adrenectomy as i said if done carefully um the i haven't found any complication as such as i said on the right side getting that right adrenal vein is a tricky one that has to be done extremely careful otherwise if you miss that the vein can just retract into that the space between the liver and the ivc that is one difficult uh position to get that vein i have seen in others in videos in conferences but i haven't encountered encountered that complication but then getting that wing can be really difficult uh because and it can bleed massively from the ivc directly so right side getting that vein is crucial uh other than that i haven't found any complication but any surgery you have to be careful uh why don't we use ecg guided i guess he's asking usg guided quoting amish i think so um that is not essential that is not possible also we have dc ports available dc ports are ports through which you can place a camera and then you can just go in you can find each layer of the abdominal wall as you go in like the once you just place an incision on the skin and then you go through the pad plane uh the the anti-directed sheath the muscular muscle layer and then the posterior sheath and the peritoneum so each layer you can identify and then go under vision you can place the port into the abdominal cavity but i am not aware of any techniques of the usg guided i don't know whether you mean to identify the position to place the port but that is usually not required [Music] can a malignant gland be removed through the camera port or separate incision can be removed through any any port either the camera or the other incision port we usually take it out through the camera boot because we have already placed an incision there the other ones are just puncture injuries or puncture wounds so um we have an incision now for the camera so you can just extend that depending on the size of the swelling and then just retrieve it through that that makes it easier it is always safer to bag the swelling rather than taking it in uh without the bag because there is always a chance of spillage or rupture of the swelling which can cause uh seeding of the tumor cells in the outside so that can be dangerous and can lead to recurrence of the malignancy so always safer to back the swelling and take it out yes whatever is yes i think although we've gone through all the questions um thank you so much uh so for this fantastic uh session uh dr kumar sonal i'm accepting your request hello sir sir uh i would like to ask that do you regularly use modulator while extracting the specimen through the endo bag uh we use it uh not no definitely not for malignant swellings but other benign swellings if they're really a large uh we we morsellate like um when in urology we have this polycystic kidney or even simple affect me when we do uh when we are sure that it's not malignant we can just morsellate it uh we don't do it inside a bag it can be done i've seen people doing that we just modulate it and just take it out and then give a wash to the abdominality you can place it inside a bag and uh take it out uh no harm in that but definitely have to make sure there's no malignancy [Music] so the only way for that is through the radiological investigation uh what my preference is that i use mosculator in most of the cases to reduce the specimen size means import size incision yeah you can do that you can definitely do that yeah two two quarter indicator instead one is malignancy second is tuberculosis yes exactly thank you sir for coming up on stage and uh thank you dr vijay for coming on to netflix and we hope to have you on our platform further for more coming up talks first time experience uh i enjoyed doing it thank you so much uh we also enjoyed the session we are also excited that we you came up on our platform sorry for the interruption but uh thank you so much sir for coming up on stage uh coming up onto the platform i'm sure our audience has have learned a lot from your experience and we look forward to more such sessions uh from you on our platform thank you sir and thank you organs for uh joining in

BEING ATTENDED BY

Dr. Patel Hirni & 487 others

SPEAKERS

dr. Vijay Radhakrishnan

Dr. Vijay Radhakrishnan

Senior Consultant, Urology, Mar Sleeva Medicity Palai

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dr. Vijay Radhakrishnan

Dr. Vijay Radhakrishnan

Senior Consultant, Urology, Mar Sleeva Medici...

+ Details

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