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TECHNIQUE OF ROBOTIC ASSISTED, LAPAROSCOPIC PELVIC LYMPHADENECTOMY
Vol. 179, No. 4, Supplement, Wednesday, May 21, 2008
SURYLGH WKH VDPH SRWHQWLDO WKHUDSHXWLF EHQH¿WV WKDW DUH SURYLGHG E\ open surgery.
THE JOURNAL OF UROLOGY®
711
DGHTXDWHGLVVHFWLRQRIWKHDGUHQDOJODQG(DUO\LGHQWL¿FDWLRQDQGGLYLVLRQ of the adrenal vein reduces potential hypertensive crisis. Early use of LQWUDRSHUDWLYHXOWUDVRXQGLPSURYHVWXPRUORFDOL]DWLRQ3UHVHUYDWLRQRI the blood supply from Gerota’s fascia to the remaining adrenal gland should be maintained. CONCLUSIONS: Laparoscopic adrenal sparing surgery for masses in the retrocaval location is technically challenging. Our experience shows that this procedure is both safe and feasible. Source of Funding: NIH Intramural Research.
V2065
Source of Funding: None
V2064 RETROCAVAL PHEOCHROMOCYTOMAS: TIPS FOR SUCCESSFUL LAPAROSCOPIC ADRENAL-SPARING SURGERY Kiranpreet Khurana*, Nick Liu, Compton Benjamin, Adam Metwalli, Peter A Pinto, Gennady Bratslavsky. Bethesda, MD. INTRODUCTION AND OBJECTIVE: Laparascopic adrenalectomy has become the standard of care for resection of adrenal masses. For patients at risk of recurrence due to inherited syndromes, such as von Hippel Lindau, multiple endocrine neoplasia II, and succinate GHK\GURJHQDVH GH¿FLHQF\ DGUHQDO VSDULQJ VXUJHU\ LV XQGHUWDNHQ to preserve adrenal function. We have previously demonstrated that laparoscopic partial adrenalectomy provides effective disease control and prevents steroid dependence. Retrocaval masses pose special technical challenges. This video demonstrates our technique for adrenal sparing laparoscopic transperitoneal management of these masses. 0(7+2'6 7KH¿UVWSDWLHQWLVD\HDUROGPDOHZLWKYRQ Hippel Lindau disease being followed in the National Cancer Institute. His past surgical history includes contralateral total adrenalectomy. On computed tomography images, two retrocaval lesions at the level of the portal vein above the celiac trunk were seen. The second patient is a 23 year old male with von Hippel Lindau disease. His past surgical history includes contralateral partial adrenalectomy. A retrocaval mass on computed tomography imaging was seen. The third patient is a 44 year old female with von Hippel Lindau disease who presented with a solitary retrocaval mass as seen on computed tomography imaging. RESULTS: Several techniques help in the resection of challenging retrocaval masses in adrenal sparing surgery. Placing the SDWLHQWLQH[WUHPHÀDQNSRVLWLRQLVFULWLFDOLQJDLQLQJDFFHVVWRWKHDGUHQDO PDVVHVLQUHWURFDYDOVSDFH+LJKPRELOL]DWLRQRIWKHOLYHUSURYLGHVIRU
TECHNIQUE OF ROBOTIC ASSISTED, LAPAROSCOPIC PELVIC LYMPHADENECTOMY Barry M Mason*, Reza Ghavamian. Bronx, NY. INTRODUCTION AND OBJECTIVE: Recent concerns have been raised regarding the feasibility of an adequate pelvic lymph node dissection during robotic cystectomy. Given the arrangement of the robotic ports, the cephalad extension of the dissection has been GHHPHGGLI¿FXOWWRDFKLHYHDQGGXSOLFDWHGXHWROLPLWHGGLVVHFWLQJDUP reach or exposure. Herein we present a video that demonstrates the feasibility of robotic assisted, pelvic lymphadenectomy, duplicating the open technique. METHODS: This video demonstrates the technique of a bilateral pelvic lymphadenectomy’s being performed after a robotic assisted, laparoscopic cystoprostatectomy using the da Vinci surgical system. Our technique involves 6 total ports, four of which are robotic and two of which are for the laparoscopic assistant. The limits of our lymphatic dissection included all the lymphatic tissue up to the obturator nerve laterally, the genitofemoral nerve medially, the node of Cloquet distally, and to just proximal of the bifurcation of the common iliac vessels. RESULTS: This video includes several very important teaching points. The robotic ports are positioned along the same line DV WKH XPELOLFXV UDWKHU WKDQ WKH W\SLFDO IDQ VKDSHG FRQ¿JXUDWLRQ (slightly higher than usual). One crucial feature of our dissection includes meticulous and haemostatic dissection of the lymphatic tissue off the anatomic iliac vasculature. In addition, as the lymphatic tissue is removed it is progressively placed within an entrapment sac as the dissection progresses. The limits of the dissection are outlined and they mirror the open lymphadenectomy for bladder cancer. Lymphatic tissue posterior, medial and deep to the obturator nerve are easily accessed. )LQDOO\WKHYLGHRGHPRQVWUDWHVKRZZHXWLOL]HWKHIRXUWKURERWLFDUPDV a stationary, intracorporeal retractor to facilitate the proximal lymphatic GLVVHFWLRQ%\XVLQJWKHIRXUWKURERWLFDUPWKHVXUJHRQFDQYLVXDOL]HDQG atraumatically retract the common iliac vessels and can safely dissect the lymphatic tissue. Fifteen and thirteen lymph nodes were removed from the left and right side respectively. CONCLUSIONS: This video demonstrates how the important oncologic and surgical features of open pelvic lymphadenectomy can be translated into a minimally invasive technique and its easy feasibility. It allows for an adequate lymphadenectomy, as measured by the number of nodes removed, and by its ability to reach the classical boundaries of resection. Source of Funding: None
V2066 TECHNIQUE OF LEFT ROBOT-ASSISTED LAPAROSCOPIC ADRENALECTOMY Herman S Bagga, Adam Levinson, David J Hernandez, Jeffrey Piacitelli, Li-Ming Su*. Baltimore, MD. INTRODUCTION AND OBJECTIVE: Laparoscopic applications of the da Vinci® Surgical System continue to expand as more centers gain experience with the technology. Experimentation with robot-assisted laparoscopic adrenalectomy (RALA) has resulted in differing success rates. We present technical suggestions which may be useful to centers seeking to offer RALA, based on our experience with the technique. METHODS: A video and schematic review of the operative preparation and surgical technique of RALA is performed, in a casebased format.
SURYLGH WKH VDPH SRWHQWLDO WKHUDSHXWLF EHQH¿WV WKDW DUH SURYLGHG E\ open surgery.
THE JOURNAL OF UROLOGY®
711
DGHTXDWHGLVVHFWLRQRIWKHDGUHQDOJODQG(DUO\LGHQWL¿FDWLRQDQGGLYLVLRQ of the adrenal vein reduces potential hypertensive crisis. Early use of LQWUDRSHUDWLYHXOWUDVRXQGLPSURYHVWXPRUORFDOL]DWLRQ3UHVHUYDWLRQRI the blood supply from Gerota’s fascia to the remaining adrenal gland should be maintained. CONCLUSIONS: Laparoscopic adrenal sparing surgery for masses in the retrocaval location is technically challenging. Our experience shows that this procedure is both safe and feasible. Source of Funding: NIH Intramural Research.
V2065
Source of Funding: None
V2064 RETROCAVAL PHEOCHROMOCYTOMAS: TIPS FOR SUCCESSFUL LAPAROSCOPIC ADRENAL-SPARING SURGERY Kiranpreet Khurana*, Nick Liu, Compton Benjamin, Adam Metwalli, Peter A Pinto, Gennady Bratslavsky. Bethesda, MD. INTRODUCTION AND OBJECTIVE: Laparascopic adrenalectomy has become the standard of care for resection of adrenal masses. For patients at risk of recurrence due to inherited syndromes, such as von Hippel Lindau, multiple endocrine neoplasia II, and succinate GHK\GURJHQDVH GH¿FLHQF\ DGUHQDO VSDULQJ VXUJHU\ LV XQGHUWDNHQ to preserve adrenal function. We have previously demonstrated that laparoscopic partial adrenalectomy provides effective disease control and prevents steroid dependence. Retrocaval masses pose special technical challenges. This video demonstrates our technique for adrenal sparing laparoscopic transperitoneal management of these masses. 0(7+2'6 7KH¿UVWSDWLHQWLVD\HDUROGPDOHZLWKYRQ Hippel Lindau disease being followed in the National Cancer Institute. His past surgical history includes contralateral total adrenalectomy. On computed tomography images, two retrocaval lesions at the level of the portal vein above the celiac trunk were seen. The second patient is a 23 year old male with von Hippel Lindau disease. His past surgical history includes contralateral partial adrenalectomy. A retrocaval mass on computed tomography imaging was seen. The third patient is a 44 year old female with von Hippel Lindau disease who presented with a solitary retrocaval mass as seen on computed tomography imaging. RESULTS: Several techniques help in the resection of challenging retrocaval masses in adrenal sparing surgery. Placing the SDWLHQWLQH[WUHPHÀDQNSRVLWLRQLVFULWLFDOLQJDLQLQJDFFHVVWRWKHDGUHQDO PDVVHVLQUHWURFDYDOVSDFH+LJKPRELOL]DWLRQRIWKHOLYHUSURYLGHVIRU
TECHNIQUE OF ROBOTIC ASSISTED, LAPAROSCOPIC PELVIC LYMPHADENECTOMY Barry M Mason*, Reza Ghavamian. Bronx, NY. INTRODUCTION AND OBJECTIVE: Recent concerns have been raised regarding the feasibility of an adequate pelvic lymph node dissection during robotic cystectomy. Given the arrangement of the robotic ports, the cephalad extension of the dissection has been GHHPHGGLI¿FXOWWRDFKLHYHDQGGXSOLFDWHGXHWROLPLWHGGLVVHFWLQJDUP reach or exposure. Herein we present a video that demonstrates the feasibility of robotic assisted, pelvic lymphadenectomy, duplicating the open technique. METHODS: This video demonstrates the technique of a bilateral pelvic lymphadenectomy’s being performed after a robotic assisted, laparoscopic cystoprostatectomy using the da Vinci surgical system. Our technique involves 6 total ports, four of which are robotic and two of which are for the laparoscopic assistant. The limits of our lymphatic dissection included all the lymphatic tissue up to the obturator nerve laterally, the genitofemoral nerve medially, the node of Cloquet distally, and to just proximal of the bifurcation of the common iliac vessels. RESULTS: This video includes several very important teaching points. The robotic ports are positioned along the same line DV WKH XPELOLFXV UDWKHU WKDQ WKH W\SLFDO IDQ VKDSHG FRQ¿JXUDWLRQ (slightly higher than usual). One crucial feature of our dissection includes meticulous and haemostatic dissection of the lymphatic tissue off the anatomic iliac vasculature. In addition, as the lymphatic tissue is removed it is progressively placed within an entrapment sac as the dissection progresses. The limits of the dissection are outlined and they mirror the open lymphadenectomy for bladder cancer. Lymphatic tissue posterior, medial and deep to the obturator nerve are easily accessed. )LQDOO\WKHYLGHRGHPRQVWUDWHVKRZZHXWLOL]HWKHIRXUWKURERWLFDUPDV a stationary, intracorporeal retractor to facilitate the proximal lymphatic GLVVHFWLRQ%\XVLQJWKHIRXUWKURERWLFDUPWKHVXUJHRQFDQYLVXDOL]HDQG atraumatically retract the common iliac vessels and can safely dissect the lymphatic tissue. Fifteen and thirteen lymph nodes were removed from the left and right side respectively. CONCLUSIONS: This video demonstrates how the important oncologic and surgical features of open pelvic lymphadenectomy can be translated into a minimally invasive technique and its easy feasibility. It allows for an adequate lymphadenectomy, as measured by the number of nodes removed, and by its ability to reach the classical boundaries of resection. Source of Funding: None
V2066 TECHNIQUE OF LEFT ROBOT-ASSISTED LAPAROSCOPIC ADRENALECTOMY Herman S Bagga, Adam Levinson, David J Hernandez, Jeffrey Piacitelli, Li-Ming Su*. Baltimore, MD. INTRODUCTION AND OBJECTIVE: Laparoscopic applications of the da Vinci® Surgical System continue to expand as more centers gain experience with the technology. Experimentation with robot-assisted laparoscopic adrenalectomy (RALA) has resulted in differing success rates. We present technical suggestions which may be useful to centers seeking to offer RALA, based on our experience with the technique. METHODS: A video and schematic review of the operative preparation and surgical technique of RALA is performed, in a casebased format.