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THORACOSCOPIC TRANSDIAPHRAGMATIC ADRENALECTOMY: THE INITIAL EXPERIENCE
0022-5347/01/1656-1875/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 165, 1875–1881, June 2001 Printed in U.S.A.
THORACOSCOPIC TRANSDIAPHRAGMATIC ADRENALECTOMY: THE INITIAL EXPERIENCE INDERBIR S. GILL,* ANOOP M. MERANEY, JOHN C. THOMAS, GYUNG TAK SUNG, ANDREW C. NOVICK AND ISADOR LIEBERMAN From the Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute and the Minimally Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, Ohio
ABSTRACT
Purpose: We introduce the technique of thoracoscopic transdiaphragmatic adrenalectomy. Materials and Methods: Initially in 4 human cadavers bilateral thoracoscopic nephrectomy was performed to develop the technique of diaphragmatic incision, retroperitoneal control of renal artery and vein, circumferential mobilization of the kidney and adrenal gland, and suture repair of the diaphragm. Subsequently, 3 select patients underwent thoracoscopic transdiaphragmatic adrenalectomy (2 right side and 1 left side). All 3 patients had significant prior abdominal scarring after either partial or total radical nephrectomy, thereby precluding efficient transabdominal laparoscopic access to the adrenal gland. After double lumen endotracheal intubation, a 4 port transthoracic approach without pneumo-insufflation was performed with the patient in the prone position. The diaphragm was incised under real-time laparoscopic ultrasound guidance. The adrenal gland was visualized high in the retroperitoneum, the vasculature controlled, and the specimen entrapped and extracted intact through a thoracic port site. The diaphragm was suture repaired with freehand laparoscopic suturing and intracorporeal knot tying. A chest tube was inserted in the initial 2 patients. Results: There were no intraoperative or postoperative complications. Operating time was 4.5, 6.5 and 2.5 hours, and blood loss was 150, 500 and 50 cc, respectively. Mean narcotic analgesic requirement was 27 mg. morphine sulfate equivalent. Hospital stay was 2 days for all 3 patients. Pathology revealed metastatic renal cell carcinoma in 2 patients and myelolipoma in 1. Conclusions: In select patients with significant concomitant intraperitoneal and retroperitoneal scarring from prior major abdominal or renal surgery laparoscopic adrenalectomy can be safely performed with the transthoracic transdiaphragmatic approach. We present our initial experience. KEY WORDS: thoracoscopy, adrenalectomy, laparoscopy
For the majority of patients with surgical adrenal disease, adrenalectomy is increasingly performed laparoscopically at many institutions worldwide. Currently, laparoscopic adrenalectomy can be efficiently performed either transperitoneally1 or retroperitoneally.2 Although these 2 laparoscopic procedures are adequate for the vast majority of patients, there is significant difficulty with the presence of prior surgical adhesions in the abdomen. Generally, in patients who have undergone major open transabdominal surgery, the presence of adhesions might preclude transperitoneal laparoscopy. In these cases we and others have successfully used retroperitoneal laparoscopy, wherein the virgin retroperitoneal space is directly accessed to advantage.2, 3 However, in the occasional patient in whom the transperitoneal and retroperitoneal spaces have already been violated open surgically, neither laparoscopic approach may be subsequently used routinely with confidence. Therefore, such a clinical situation may prevail in the occasional patient in whom a metachronous solitary adrenal lesion develops after ipsilateral radical, total or partial nephrectomy through an extraperitoneal 11th rib incision followed by a staged contralateral renal or adrenal procedure through transperitoneal Chevron incision for bilateral renal carcinoma or benign end stage disease. In such select circumstances, given the high location of the
adrenal gland in the retroperitoneum in close juxtaposition to the undersurface of the diaphragm, a minimally invasive transthoracic transdiaphragmatic approach to the adrenal gland through the virgin thoracic cavity is attractive. We present the technique and initial experience with thoracoscopic transdiaphragmatic adrenalectomy.
MATERIALS AND METHODS
Thoracoscopic transdiaphragmatic access was first developed in human cadavers. Bilateral thoracoscopic transdiaphragmatic nephrectomy was performed in 4 human cadavers. The cadaver was secured in the full flank left lateral position (right side up). The right arm was placed on an overhead arm rest. A 10 mm. trocar was introduced in the 7th intercostal space just below the scapula tip. The thorax was insufflated with carbon dioxide at a pressure of 10 mm. Hg. A 30 degree 10 mm. laparoscope was introduced and the intrathoracic viscera inspected. There were 3 secondary ports inserted under laparoscopic guidance, including a 5 mm. trocar in the 8th intercostal space in the mid axillary line, a 5 mm. port in the 8th intercostal space about 5 cm. behind the posterior axillary line and a 10 mm. port in the 5th intercostal space in the anterior axillary line. The 2, 5 mm. ports were used as working channels for laparoscopic instruments, and the 10 mm. port was used to insert a fan retractor to retract the ipsilateral lung. After identifying the supradiaphragmatic inferior
Accepted for publication December 21, 2000. * Requests for reprints: Urological Institute A-100, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, Ohio 44195. 1875
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vena cava and taking care to avoid it, the diaphragm was incised in the posterolateral part with Endoshears.† An 8 to 12 cm. diaphragmatic incision was made starting laterally, at least 2 cm. away from the thoracic wall and extending posteriorly in a curvilinear fashion. The incision was deepened through the full thickness of the diaphragmatic musculature. The retroperitoneal fat was visualized and fibers of the psoas muscle were identified along the posterior aspect of the operative field. The 10 mm. fan retractor was advanced through the diaphragmatic incision into the retroperitoneum, and used to lift and anteriorly retract the peritoneum covered liver. This maneuver readily created a large working space in the retroperitoneum, with resultant easy visualization of Gerota’s fascia. The vena cava was visualized, and the renal artery and vein individually dissected, clip occluded and divided. The kidney was circumferentially freed and either left behind in the retroperitoneum or withdrawn into the thorax. The diaphragmatic incision was suture repaired with continuous 2-zero nonabsorbable suture using the Endo Stitch device. The cadaver was then repositioned on the contralateral flank, and transthoracic left nephrectomy was performed in a similar manner. Three patients underwent thoracoscopic transdiaphragmatic adrenalectomy (right side 2, left side 1). CASE HISTORIES
Case 1. A 62-year-old male had undergone open right radical nephrectomy for cancer through an extraperitoneal 11th rib incision, followed by staged open left adrenalectomy through a Chevron incision for adrenal metastasis. During followup abdominal computerized tomography (CT) revealed a new 3.5 cm. irregular, heterogenous right adrenal mass suspicious for metachronous adrenal metastasis. The remainder of the metastatic evaluation was negative. Given the significant possibility of prior dense transperitoneal and retroperitoneal postoperative adhesions, thoracoscopic transdiaphragmatic right adrenalectomy was performed on December 9, 1999. Case 2. A 64-year-old male had undergone right partial nephrectomy for cancer through an extraperitoneal 11th rib incision, left radical nephrectomy for cancer through a Chevron incision, as well as open cholecystectomy and appendec† U.S. Surgical Corp., Norwalk, Connecticut.
FIG. 2. Patient prone on orthopedic spinal table. Care is taken to confirm that abdominal excursions are unrestricted.
tomy. During followup a 2.4 cm. right adrenal mass was identified, suggestive of solitary metachronous adrenal metastasis. Thoracoscopic transdiaphragmatic right adrenalectomy was performed. Case 3. A 20-year-old female with renal failure on hemodialysis had undergone bilateral open nephrectomy for end stage hypertensive nephropathy. Persistent intractable hypertension for 2 years after nephrectomy, resistant to 4 antihypertensive medications, was evaluated biochemically, which revealed a moderately increased dopamine level of 61 mg./ml. (normal 0 to 20). Plasma epinephrine, norepinephrine and aldosterone, and urinary metanephrine, normetanephrine and vanillylmandelic acid levels were normal. Abdominal CT revealed a 3 cm. left adrenal mass, which was noted to have increased from 2.8 cm. on a previous CT (fig. 1). Thoracoscopic transdiaphragmatic left adrenalectomy was performed. TECHNIQUE
General anesthesia is obtained with select double lumen endotracheal intubation, leaving the ipsilateral lung not in-
FIG. 1. CT shows 3 cm. left adrenal mass
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FIG. 3. Schematic diagram outlining port placement for right thoracoscopic transthoracic adrenalectomy
flated. Auscultation confirms absence of breath sounds in the ipsilateral hemithorax. The patient is then positioned prone on a radiolucent spinal frame table, and care is taken to ensure that respiratory excursions of the anterior abdominal wall are unrestricted (fig. 2). Both arms are adducted, and the back is prepared and draped widely extending beyond the anterior axillary line on each side. A 4 port transthoracic approach is used (fig. 3). The initial port is placed at the junction of the posterior axillary line and 7th rib. All ports are valveless and 12 mm. in size. To insert a port, a 1.5 cm. transverse incision is made directly over the underlying rib. Using a Kelly clamp, the incision is bluntly deepened until the rib surface is reached. Blunt dissection is then performed with the Kelly clamp immediately along the superior edge of the rib, bluntly gaining entry into the pleural cavity. Thus, care is taken to avoid iatrogenic damage to the intercostal neurovascular bundle or lung. The 10 to 12 mm. blunt tipped port is inserted, and the thoracic cavity is inspected with a 10 mm. 30 degree laparoscope. Since the ipsilateral lung remains collapsed because of the double lumen endotracheal tube, there is ample working space in the ipsilateral hemithorax (fig. 4, A). With the patient prone the deflated ipsilateral lung falls out of view spontaneously, requiring no active retraction. Therefore, pneumothorax is not necessary, and carbon dioxide insufflation is not performed. Three secondary ports are secured (fig. 4, B). A flexible, steerable color Doppler ultrasound probe is inserted through a lateral port and positioned
FIG. 4. A, thoracoscopic view of right hemithorax after placement of primary port shows collapsed right lung (L), various ribs, intercostal vessels, azygos venous system (A) and thoracic spine (T). Carbon dioxide insufflation is not used. B, 4 port approach for right thoracic adrenalectomy. Because no carbon dioxide insufflation is necessary, valveless trocars are used. Triangular shaded area represents right scapula. H, head end of patient. Midline, spine. C, steerable flexible color Doppler ultrasound probe is placed in contact with diaphragm.
directly in contact with the pleural surface of the hemidiaphragm (fig. 4, C). Real-time visualization identifies the precise location of the adrenal mass on the other side of the
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FIG. 5. A, transdiaphragmatic ultrasound of 2.9 ⫻ 2.8 cm. right adrenal gland outlined by 4 ultrasound cursors. Color Doppler identifies inferior vena cava (blue) adjacent to adrenal gland. Inset shows ultrasound probe placed in contact with diaphragm. B, diaphragm is scored radially with electrocautery J-hook probe (arrow). C, repeat ultrasonography confirms that proposed line of diaphragmatic incision (arrowhead) directly overlies adrenal gland (curved arrow). Inset shows ultrasound probe in contact with diaphragm. D, on completion of full thickness diaphragmatic incision, retroperitoneal periadrenal fat (F) is visualized immediately.
FIG. 6. A, adrenal gland (arrow) is mobilized and delivered through diaphragmatic incision into thorax. B, diaphragmatic incision is suture repaired in airtight manner with freehand laparoscopic 2-zero polyglactin suture on CT 1 needle and interlocking stitches.
diaphragm relative to the edge of the liver and inferior vena cava on the right side (fig. 5, A), or the edge of the spleen and aorta on the left side. The diaphragm is scored radially with electrocautery along the proposed incision site (fig. 5, B). Repeat ultrasonography confirms that the proposed line of diaphragmatic incision directly and precisely overlies the adrenal mass (fig. 5, C). Using an electrosurgical J-hook, a 6 to 7 cm. incision is made through the full thickness of the diaphragm muscular wall, maintaining complete hemostasis. Retroperitoneal fat surrounding the adrenal gland, along with the surface of the liver or spleen, is visualized immediately (fig. 5, D). To gain additional exposure of the adrenal gland, diaphragmatic incision is extended as necessary, care being taken to maintain a distance of at least 2 cm. from the chest wall.
The superomedial and superolateral aspects of the adrenal gland are mobilized and the inferior phrenic vessels controlled (fig. 6, A). Meticulous hemostasis is critical at all times, and dissection is best performed with an electrosurgical J-hook in a slow deliberate manner. During right adrenalectomy dissection is performed between the adrenal gland and inferior vena cava, in which the main right adrenal vein is visualized. An articulating 30 mm. cartridge Endo-GIA† stapler (vascular) is precisely positioned to secure and transect the main right adrenal vein. Continued caudal dissection reveals multiple adrenal branches from the renal hilum, which are clipped and divided, thus freeing the adrenal gland completely. During left adrenalectomy dissection along the inferior medial aspect of the gland reveals the longer, obliquely oriented left main adrenal vein, which is secured with a Endo-GIA stapler, thus freeing the
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INITIAL EXPERIENCE WITH THORACOSCOPIC TRANSDIAPHRAGMATIC ADRENALECTOMY TABLE 1. Thoracoscopic transdiaphragmatic nephrectomy: human cadaveric study Variables No. subjects Mean surgical time (mins.) Individual steps (mins.): Diaphragmatic incision Hilar dissection Renal vessel control Diaphragmatic repair Diaphragmatic incision length (cm.) No. inadvertent celiotomy Ureteral length (cm.)
Lt. Nephrectomy (range)
Rt. Nephrectomy (range)
4 64.3 (54–76)
4 82.5 (72–90)
11 (10–13) 26.2 (24–31) 10.2 (9–11) 19.2 (16–23) 10 (8–12)
11.5 (10–13) 31 (29–36) 13 (11–15) 22.2 (20–25) 9.5 (8–12)
1 5.6 (3.5–8)
1 3.9 (3–4.5)
adrenal gland. The specimen is retrieved into the thorax, entrapped in an Endo Catch† bag, and extracted intact through a port site. Hemostasis is confirmed and a thrombin soaked absorbable hemostatic agent is placed in the adrenal bed. The diaphragm is suture repaired in an airtight manner by a running locking 2-zero polyglactin suture on a CT 1 needle. Freehand laparoscopic suturing and intracorporeal knot tying techniques are used exclusively (fig. 6, B). The pleural cavity is thoroughly irrigated and hemostasis confirmed. Ports are removed under thoracoscopic visualization. In cases 1 and 2 a 34Fr chest tube was inserted through a lateral port and attached to water seal suction. In case 3 no chest tube was used. Instead, each port site was closed with a figure-of-8 2-zero polyglactin suture in the intercostal muscles, which was tied down with the ipsilateral lung maintained in full inhalation by the anesthesiologist, after unclamping the double lumen endotracheal tube. Skin closure was achieved with 4-zero polyglactin subcuticular sutures. RESULTS
Experimental. Transthoracic transdiaphragmatic bilateral nephrectomy was successful in all 8 kidneys (left side 4, right
side 4, table 1). Mean surgical time was 64.3 minutes on the left side and 82.5 minutes on the right side. Inadvertent peritoneotomy occurred during specimen mobilization in 2 instances, which did not compromise intraoperative exposure. Diaphragmatic repair was feasible on each occasion, and no inadvertent injury to adjacent organs was noted. Clinical. Detailed demographic, intraoperative and postoperative data on the 3 clinical cases are presented in table 2. All 3 patients had undergone considerable prior transperitoneal and retroperitoneal open surgery. In the initial 2 cases of solitary adrenal metastasis operating times were lengthy (4.5 and 6.5 hours), with a blood loss of 150 and 500 cc, respectively. The majority of this blood loss was because of peri-adrenal reaction and neovascularity secondary to malignancy. In the third case of an adrenal myelolipoma operating time was 2.5 hours and blood loss was 50 cc. Satisfactory airtight suture repair of the diaphragmatic incision was achieved with freehand laparoscopic suturing and intracorporeal knot tying techniques in all 3 cases, as with increasing experience, a chest tube was not believed to be necessary in the third case (fig. 7). Hemodynamic and capnometric parameters were normal in each case. Postoperatively the ipsilateral hemidiaphragm was documented to have normal respiratory excursions on fluoroscopic examination of the chest in both patients who agreed to undergo the test. During 8, 4 and 2-month followup, respectively, no complications occurred. The adrenal bed appeared free of local recurrence on CT in the 2 patients with adrenal cancer. DISCUSSION
Endoscopic techniques and technology are revolutionizing surgical approaches across virtually all surgical subspecialties, including urology. Initially described in the 1920s, thoracoscopy has evolved from a purely diagnostic tool to complex therapeutic procedures for pulmonary, mediastinal, spinal, esophageal and cardiac pathologies.4 – 6 In 1992 Mack et al first performed thoracoscopic transdiaphragmatic inci-
TABLE 2. Thoracoscopic transdiaphragmatic adrenalectomy: clinical experience Operation date Sex/age (yrs.) Body mass index American Society of Anesthesiologists class Prior abdominal surgery
Case 1
Case 2
Case 3
12/9/99 Male/62 21.4 3 Rt. radical nephrectomy, lt. adrenalectomy Rt. 3.5 Prone 4 150 4.5 25 None 3,300
4/13/00 Male/64 40 3 Lt. radical nephrectomy, rt. partial nephrectomy, cholecystectomy, appendectomy Rt. 2.4 Prone 4 500 6.5 28 None 4,000
6/8/00 Female/20 20 3 Bilat. nephrectomy
Adrenal side Adrenal size (cm.) Pt. position No. ports Blood loss (cc) Total surgical time (hrs.) Diaphragm suturing time (mins.) Inadvertent celiotomy Intraop. intravenous fluids (cc) Pulse rate/min.: Max. 120 136 Min. 76 70 Blood pressure: Max. 180/90 180/100 Min. 120/60 108/64 End tidal carbon dioxide (mm. Hg): Max. 36 40 Min. 25 33 Chest tube Yes, overnight Yes, overnight Resume ambulation (days) 1 1 Resume oral intake (days) 1 1 Morphine sulfate analgesia (mg.) 18 24 Hospital stay (days) 2 2 Convalescence (wks.) 4 4 Postop. diaphragm mobility* N/A Normal Adrenal wt. (gm.) 12 17 Pathological diagnosis Metastatic renal cell Ca Metastatic renal cell Ca Complications None None Followup (mos.) 8 4 * Movement of the postoperative hemidiaphragm was evaluated by fluoroscopic examination of the chest.
Lt. 2.8 Prone 4 50 2.5 18 None 1,500 112 54 190/100 90/50 39 28 No 1 1 38 2 8 Normal 12 Myelolipoma None 2
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FIG. 7. Case 3. Chest x-ray immediately after thoracoscopic left adrenalectomy. Chest tube was not used postoperatively. Left lung is completely expanded without any evidence of pneumothorax.
sional biopsy of the left adrenal gland.7 In 1997 Pompeo et al described transthoracic left adrenalectomy in the porcine model.8 Thoracoscopic repair of the diaphragmatic incision has been performed by endoscopic suturing or staples.8, 9 We recently reported thoracoscopic transdiaphragmatic bilateral nephrectomy in an acute porcine model.10 Thoracic access was obtained with 3 ports and the diaphragm was incised to gain entry into the retroperitoneum in which the feasibility of individual control of the renal artery and vein, and circumferential mobilization of the kidney were demonstrated. The diaphragm was repaired with the Endo Stitch device using continuous suture. In 4 acute pigs mean surgical time was 69.3 minutes for left nephrectomy and 74.3 minutes for right nephrectomy, with a mean blood loss of 18.7 cc. Mean diaphragmatic incision was 7.2 cm. The transthoracic 10 mm. fan retractor could adequately retract the spleen and liver during left sided and right sided nephrectomy, respectively. Intraoperative arterial blood gas parameters were acceptable.10 Based on this porcine study, we proceeded with refining the technique in human cadavers. In our cadaveric study we sought to develop a procedure for thoracoscopic nephrectomy and extrapolate this approach to adrenal surgery as necessary. With the cadaver placed in the lateral position, considerable transthoracic retraction of the liver or spleen was required to achieve the necessary exposure. Nevertheless, the retroperitoneal space could be accessed and developed satisfactorily, and individual control of the renal artery and vein was possible in all 8 procedures. Mean surgical time was 64.3 minutes for left nephrectomy and 82.5 minutes for right nephrectomy. Hilar dissection required approximately a half hour on either side, and no injury to the renal vessels occurred. On average, the diaphragmatic incision was approximately 10 cm., and suture repair of the diaphragm could be performed adequately. Encouraged by our porcine and human cadaveric experience, we proceeded to clinical application. The impetus for exploring the transthoracic approach was
our desire to offer an adequate minimally invasive option to select candidates for adrenalectomy, who have significant concomitant scarring of the intraperitoneal and retroperitoneal spaces. On 2 previous occasions we have performed transperitoneal laparoscopic adrenalectomy in patients who had undergone contralateral open transperitoneal radical nephrectomy followed by staged ipsilateral extraperitoneal open partial nephrectomy for bilateral renal cell carcinoma. Our experience in these patients underscored the technical difficulty of transabdominal laparoscopic adrenalectomy in such a setting. Therefore, we sought to explore the virgin thoracic cavity as a possible access route to the pathological adrenal gland. The thoracoscopic transdiaphragmatic procedure requires a detailed knowledge of thoracic and retroperitoneal anatomy, as well as considerable prior experience with major laparoscopy and open surgery.5, 11 Select double lumen endotracheal intubation with single lung ventilation is imperative. Therefore, the anesthesia team should be thoroughly conversant with double lumen intubation techniques. Adequate deflation of the appropriate lung on clamping the double lumen tube is confirmed by auscultation on 3 separate occasions, including at intubation, after prone positioning and before skin incision.11 A bronchoscope should immediately be available in the operating room, and the double lumen tube is monitored continuously for adequate functioning. For preoperative planning, 3-dimensional CT reconstruction of the adrenal gland with vector projection is useful to plan trocar placement. Because no pneumo-insufflation is used, valved trocars are unnecessary. We used rigid valveless ports (fig. 4, B), which allow free passage of various instruments. Although active retraction of the liver or spleen was necessary in the cadaver in the lateral position, in the clinical application with the patient in the prone position, the gravity induced anterior displacement of the liver or spleen minimized the need for active retraction of these organs. Given the posterior location of the adrenal gland high in the retro-
INITIAL EXPERIENCE WITH THORACOSCOPIC TRANSDIAPHRAGMATIC ADRENALECTOMY
peritoneum, the prone position was advantageous because it allowed a direct approach to the adrenal gland. Real-time ultrasonographic guidance was an indispensable adjunct in precisely planning diaphragmatic incision directly over the adrenal gland. The articulating cartridge vascular stapler significantly expedited control of the main adrenal vein. During diaphragmatic repair, extreme care must be taken to avoid inadvertent needle puncture of the lung, which may result in a bronchopleural fistula. Certain limitations of the transthoracic transdiaphragmatic procedure are obvious.4, 12, 13 This technique would be contraindicated in patients with preexisting cardiopulmonary disease, which precludes single lung ventilation. Prior thoracic surgery with resultant postoperative pulmonary adhesions is another contraindication. Complete familiarity with thoracoscopic techniques is critical, and collaboration with an appropriate minimally invasive thoracic or spine surgeon is recommended. CONCLUSIONS
The thoracoscopic transdiaphragmatic technique is a novel minimally invasive procedure in select patients with surgical adrenal pathology. In patients in whom surgery has not been performed in the abdomen we recommend that laparoscopic adrenalectomy be done with the technically simpler transperitoneal or retroperitoneal approaches. However, in the rare patient in whom prior major abdominal surgery precludes transperitoneal and retroperitoneal laparoscopy, use of the virgin thoracic cavity appears reasonable. Precise anatomical familiarity and considerable experience with thoracoscopic and transabdominal laparoscopy are necessary. Because the learning curve is steep, we believe that prior experience with laparoscopic adrenalectomy in at least 25 to 30 cases is necessary before embarking on the thoracoscopic transdiaphragmatic approach. In addition to the indications aforementioned, in the future, it is feasible that in patients with larger adrenal14 or upper pole renal masses, thoracoscopic and transabdominal laparoscopy could be combined to provide a minimally invasive alternative to open surgical thoracoabdominal incision.
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REFERENCES
1. Gill, I. S., Soble, J. J., Sung, G. T. et al: Needlescopic adrenalectomy: the initial series: comparison with conventional laparoscopic adrenalectomy. Urology, 52: 180, 1998 2. Takeda, M., Go, H., Watanabe, R. et al: Retroperitoneal laparoscopic adrenalectomy for functioning adrenal tumors: comparison with conventional transperitoneal laparoscopic adrenalectomy. J Urol, 157: 19, 1997 3. Sung, G. T., Hsu, T. H. S. and Gill, I. S.: Retroperitoneal approach for adrenalectomy. Unpublished data 4. Dieter, R. A., Jr. and Kuzycz, G. B.: Complications and contraindications of thoracoscopy. Int Surg, 82: 232, 1997 5. Landreneau, R. J., Mack, M. J., Hazelrigg, S. R. et al: Videoassisted thoracic surgery: basic technical concepts and intercostal approach strategies. Ann Thorac Surg, 54: 800, 1992 6. Dexter, S. P., Martin, I. G. and McMahon, M. J.: Radical thoracoscopic esophagectomy for cancer. Surg Endosc, 10: 147, 1996 7. Mack, M. J., Arnoff, R. J., Acuff, T. E. et al: Thoracoscopic transdiaphragmatic approach for adrenal biopsy. Ann Thorac Surg, 55: 772, 1993 8. Pompeo, E., Coosemans, W. and De Leyn, P.: Thoracoscopic transdiaphragmatic left adrenalectomy: an experimental study. Surg Endosc, 11: 390, 1997 9. Fredman, B., Olsfanger, D. and Jedeikin, R.: Thoracoscopic sympathectomy in the treatment of palmar hyperhidrosis: anaesthetic implications. Br J Anaesth, 79: 113, 1997 10. Meraney, A. M., Gill, I. S., Hsu, T. H. et al: Thoracoscopic transdiaphragmatic nephrectomy: feasibility study. Urology, 55: 443, 2000 11. Lieberman, I. H., Salo, P. T., Orr, R. D. et al: Prone position endoscopic transthoracic release with simultaneous posterior instrumentation for spinal deformity: a description of the technique. Spine, 25: 2251, 2000 12. Yim, A. P and Liu, H. P.: Complications and failures of videoassisted thoracic surgery: experience from two centers in Asia. Ann Thorac Surg, 61: 538, 1996 13. Jancovici, R., Lang-Lazdunski, L., Pons, F. et al.: Complications of video-assisted thoracic surgery: a five year experience. Ann Thorac Surg, 61: 533, 1996 14. Hobart, M. G., Gill, I. S., Schweizer, D. et al: Laparoscopic adrenalectomy for large-volume (⬎ or ⫽5 cm) adrenal masses. J Endourol, 14: 149, 2000
Vol. 165, 1875–1881, June 2001 Printed in U.S.A.
THORACOSCOPIC TRANSDIAPHRAGMATIC ADRENALECTOMY: THE INITIAL EXPERIENCE INDERBIR S. GILL,* ANOOP M. MERANEY, JOHN C. THOMAS, GYUNG TAK SUNG, ANDREW C. NOVICK AND ISADOR LIEBERMAN From the Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute and the Minimally Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, Ohio
ABSTRACT
Purpose: We introduce the technique of thoracoscopic transdiaphragmatic adrenalectomy. Materials and Methods: Initially in 4 human cadavers bilateral thoracoscopic nephrectomy was performed to develop the technique of diaphragmatic incision, retroperitoneal control of renal artery and vein, circumferential mobilization of the kidney and adrenal gland, and suture repair of the diaphragm. Subsequently, 3 select patients underwent thoracoscopic transdiaphragmatic adrenalectomy (2 right side and 1 left side). All 3 patients had significant prior abdominal scarring after either partial or total radical nephrectomy, thereby precluding efficient transabdominal laparoscopic access to the adrenal gland. After double lumen endotracheal intubation, a 4 port transthoracic approach without pneumo-insufflation was performed with the patient in the prone position. The diaphragm was incised under real-time laparoscopic ultrasound guidance. The adrenal gland was visualized high in the retroperitoneum, the vasculature controlled, and the specimen entrapped and extracted intact through a thoracic port site. The diaphragm was suture repaired with freehand laparoscopic suturing and intracorporeal knot tying. A chest tube was inserted in the initial 2 patients. Results: There were no intraoperative or postoperative complications. Operating time was 4.5, 6.5 and 2.5 hours, and blood loss was 150, 500 and 50 cc, respectively. Mean narcotic analgesic requirement was 27 mg. morphine sulfate equivalent. Hospital stay was 2 days for all 3 patients. Pathology revealed metastatic renal cell carcinoma in 2 patients and myelolipoma in 1. Conclusions: In select patients with significant concomitant intraperitoneal and retroperitoneal scarring from prior major abdominal or renal surgery laparoscopic adrenalectomy can be safely performed with the transthoracic transdiaphragmatic approach. We present our initial experience. KEY WORDS: thoracoscopy, adrenalectomy, laparoscopy
For the majority of patients with surgical adrenal disease, adrenalectomy is increasingly performed laparoscopically at many institutions worldwide. Currently, laparoscopic adrenalectomy can be efficiently performed either transperitoneally1 or retroperitoneally.2 Although these 2 laparoscopic procedures are adequate for the vast majority of patients, there is significant difficulty with the presence of prior surgical adhesions in the abdomen. Generally, in patients who have undergone major open transabdominal surgery, the presence of adhesions might preclude transperitoneal laparoscopy. In these cases we and others have successfully used retroperitoneal laparoscopy, wherein the virgin retroperitoneal space is directly accessed to advantage.2, 3 However, in the occasional patient in whom the transperitoneal and retroperitoneal spaces have already been violated open surgically, neither laparoscopic approach may be subsequently used routinely with confidence. Therefore, such a clinical situation may prevail in the occasional patient in whom a metachronous solitary adrenal lesion develops after ipsilateral radical, total or partial nephrectomy through an extraperitoneal 11th rib incision followed by a staged contralateral renal or adrenal procedure through transperitoneal Chevron incision for bilateral renal carcinoma or benign end stage disease. In such select circumstances, given the high location of the
adrenal gland in the retroperitoneum in close juxtaposition to the undersurface of the diaphragm, a minimally invasive transthoracic transdiaphragmatic approach to the adrenal gland through the virgin thoracic cavity is attractive. We present the technique and initial experience with thoracoscopic transdiaphragmatic adrenalectomy.
MATERIALS AND METHODS
Thoracoscopic transdiaphragmatic access was first developed in human cadavers. Bilateral thoracoscopic transdiaphragmatic nephrectomy was performed in 4 human cadavers. The cadaver was secured in the full flank left lateral position (right side up). The right arm was placed on an overhead arm rest. A 10 mm. trocar was introduced in the 7th intercostal space just below the scapula tip. The thorax was insufflated with carbon dioxide at a pressure of 10 mm. Hg. A 30 degree 10 mm. laparoscope was introduced and the intrathoracic viscera inspected. There were 3 secondary ports inserted under laparoscopic guidance, including a 5 mm. trocar in the 8th intercostal space in the mid axillary line, a 5 mm. port in the 8th intercostal space about 5 cm. behind the posterior axillary line and a 10 mm. port in the 5th intercostal space in the anterior axillary line. The 2, 5 mm. ports were used as working channels for laparoscopic instruments, and the 10 mm. port was used to insert a fan retractor to retract the ipsilateral lung. After identifying the supradiaphragmatic inferior
Accepted for publication December 21, 2000. * Requests for reprints: Urological Institute A-100, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, Ohio 44195. 1875
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vena cava and taking care to avoid it, the diaphragm was incised in the posterolateral part with Endoshears.† An 8 to 12 cm. diaphragmatic incision was made starting laterally, at least 2 cm. away from the thoracic wall and extending posteriorly in a curvilinear fashion. The incision was deepened through the full thickness of the diaphragmatic musculature. The retroperitoneal fat was visualized and fibers of the psoas muscle were identified along the posterior aspect of the operative field. The 10 mm. fan retractor was advanced through the diaphragmatic incision into the retroperitoneum, and used to lift and anteriorly retract the peritoneum covered liver. This maneuver readily created a large working space in the retroperitoneum, with resultant easy visualization of Gerota’s fascia. The vena cava was visualized, and the renal artery and vein individually dissected, clip occluded and divided. The kidney was circumferentially freed and either left behind in the retroperitoneum or withdrawn into the thorax. The diaphragmatic incision was suture repaired with continuous 2-zero nonabsorbable suture using the Endo Stitch device. The cadaver was then repositioned on the contralateral flank, and transthoracic left nephrectomy was performed in a similar manner. Three patients underwent thoracoscopic transdiaphragmatic adrenalectomy (right side 2, left side 1). CASE HISTORIES
Case 1. A 62-year-old male had undergone open right radical nephrectomy for cancer through an extraperitoneal 11th rib incision, followed by staged open left adrenalectomy through a Chevron incision for adrenal metastasis. During followup abdominal computerized tomography (CT) revealed a new 3.5 cm. irregular, heterogenous right adrenal mass suspicious for metachronous adrenal metastasis. The remainder of the metastatic evaluation was negative. Given the significant possibility of prior dense transperitoneal and retroperitoneal postoperative adhesions, thoracoscopic transdiaphragmatic right adrenalectomy was performed on December 9, 1999. Case 2. A 64-year-old male had undergone right partial nephrectomy for cancer through an extraperitoneal 11th rib incision, left radical nephrectomy for cancer through a Chevron incision, as well as open cholecystectomy and appendec† U.S. Surgical Corp., Norwalk, Connecticut.
FIG. 2. Patient prone on orthopedic spinal table. Care is taken to confirm that abdominal excursions are unrestricted.
tomy. During followup a 2.4 cm. right adrenal mass was identified, suggestive of solitary metachronous adrenal metastasis. Thoracoscopic transdiaphragmatic right adrenalectomy was performed. Case 3. A 20-year-old female with renal failure on hemodialysis had undergone bilateral open nephrectomy for end stage hypertensive nephropathy. Persistent intractable hypertension for 2 years after nephrectomy, resistant to 4 antihypertensive medications, was evaluated biochemically, which revealed a moderately increased dopamine level of 61 mg./ml. (normal 0 to 20). Plasma epinephrine, norepinephrine and aldosterone, and urinary metanephrine, normetanephrine and vanillylmandelic acid levels were normal. Abdominal CT revealed a 3 cm. left adrenal mass, which was noted to have increased from 2.8 cm. on a previous CT (fig. 1). Thoracoscopic transdiaphragmatic left adrenalectomy was performed. TECHNIQUE
General anesthesia is obtained with select double lumen endotracheal intubation, leaving the ipsilateral lung not in-
FIG. 1. CT shows 3 cm. left adrenal mass
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FIG. 3. Schematic diagram outlining port placement for right thoracoscopic transthoracic adrenalectomy
flated. Auscultation confirms absence of breath sounds in the ipsilateral hemithorax. The patient is then positioned prone on a radiolucent spinal frame table, and care is taken to ensure that respiratory excursions of the anterior abdominal wall are unrestricted (fig. 2). Both arms are adducted, and the back is prepared and draped widely extending beyond the anterior axillary line on each side. A 4 port transthoracic approach is used (fig. 3). The initial port is placed at the junction of the posterior axillary line and 7th rib. All ports are valveless and 12 mm. in size. To insert a port, a 1.5 cm. transverse incision is made directly over the underlying rib. Using a Kelly clamp, the incision is bluntly deepened until the rib surface is reached. Blunt dissection is then performed with the Kelly clamp immediately along the superior edge of the rib, bluntly gaining entry into the pleural cavity. Thus, care is taken to avoid iatrogenic damage to the intercostal neurovascular bundle or lung. The 10 to 12 mm. blunt tipped port is inserted, and the thoracic cavity is inspected with a 10 mm. 30 degree laparoscope. Since the ipsilateral lung remains collapsed because of the double lumen endotracheal tube, there is ample working space in the ipsilateral hemithorax (fig. 4, A). With the patient prone the deflated ipsilateral lung falls out of view spontaneously, requiring no active retraction. Therefore, pneumothorax is not necessary, and carbon dioxide insufflation is not performed. Three secondary ports are secured (fig. 4, B). A flexible, steerable color Doppler ultrasound probe is inserted through a lateral port and positioned
FIG. 4. A, thoracoscopic view of right hemithorax after placement of primary port shows collapsed right lung (L), various ribs, intercostal vessels, azygos venous system (A) and thoracic spine (T). Carbon dioxide insufflation is not used. B, 4 port approach for right thoracic adrenalectomy. Because no carbon dioxide insufflation is necessary, valveless trocars are used. Triangular shaded area represents right scapula. H, head end of patient. Midline, spine. C, steerable flexible color Doppler ultrasound probe is placed in contact with diaphragm.
directly in contact with the pleural surface of the hemidiaphragm (fig. 4, C). Real-time visualization identifies the precise location of the adrenal mass on the other side of the
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FIG. 5. A, transdiaphragmatic ultrasound of 2.9 ⫻ 2.8 cm. right adrenal gland outlined by 4 ultrasound cursors. Color Doppler identifies inferior vena cava (blue) adjacent to adrenal gland. Inset shows ultrasound probe placed in contact with diaphragm. B, diaphragm is scored radially with electrocautery J-hook probe (arrow). C, repeat ultrasonography confirms that proposed line of diaphragmatic incision (arrowhead) directly overlies adrenal gland (curved arrow). Inset shows ultrasound probe in contact with diaphragm. D, on completion of full thickness diaphragmatic incision, retroperitoneal periadrenal fat (F) is visualized immediately.
FIG. 6. A, adrenal gland (arrow) is mobilized and delivered through diaphragmatic incision into thorax. B, diaphragmatic incision is suture repaired in airtight manner with freehand laparoscopic 2-zero polyglactin suture on CT 1 needle and interlocking stitches.
diaphragm relative to the edge of the liver and inferior vena cava on the right side (fig. 5, A), or the edge of the spleen and aorta on the left side. The diaphragm is scored radially with electrocautery along the proposed incision site (fig. 5, B). Repeat ultrasonography confirms that the proposed line of diaphragmatic incision directly and precisely overlies the adrenal mass (fig. 5, C). Using an electrosurgical J-hook, a 6 to 7 cm. incision is made through the full thickness of the diaphragm muscular wall, maintaining complete hemostasis. Retroperitoneal fat surrounding the adrenal gland, along with the surface of the liver or spleen, is visualized immediately (fig. 5, D). To gain additional exposure of the adrenal gland, diaphragmatic incision is extended as necessary, care being taken to maintain a distance of at least 2 cm. from the chest wall.
The superomedial and superolateral aspects of the adrenal gland are mobilized and the inferior phrenic vessels controlled (fig. 6, A). Meticulous hemostasis is critical at all times, and dissection is best performed with an electrosurgical J-hook in a slow deliberate manner. During right adrenalectomy dissection is performed between the adrenal gland and inferior vena cava, in which the main right adrenal vein is visualized. An articulating 30 mm. cartridge Endo-GIA† stapler (vascular) is precisely positioned to secure and transect the main right adrenal vein. Continued caudal dissection reveals multiple adrenal branches from the renal hilum, which are clipped and divided, thus freeing the adrenal gland completely. During left adrenalectomy dissection along the inferior medial aspect of the gland reveals the longer, obliquely oriented left main adrenal vein, which is secured with a Endo-GIA stapler, thus freeing the
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INITIAL EXPERIENCE WITH THORACOSCOPIC TRANSDIAPHRAGMATIC ADRENALECTOMY TABLE 1. Thoracoscopic transdiaphragmatic nephrectomy: human cadaveric study Variables No. subjects Mean surgical time (mins.) Individual steps (mins.): Diaphragmatic incision Hilar dissection Renal vessel control Diaphragmatic repair Diaphragmatic incision length (cm.) No. inadvertent celiotomy Ureteral length (cm.)
Lt. Nephrectomy (range)
Rt. Nephrectomy (range)
4 64.3 (54–76)
4 82.5 (72–90)
11 (10–13) 26.2 (24–31) 10.2 (9–11) 19.2 (16–23) 10 (8–12)
11.5 (10–13) 31 (29–36) 13 (11–15) 22.2 (20–25) 9.5 (8–12)
1 5.6 (3.5–8)
1 3.9 (3–4.5)
adrenal gland. The specimen is retrieved into the thorax, entrapped in an Endo Catch† bag, and extracted intact through a port site. Hemostasis is confirmed and a thrombin soaked absorbable hemostatic agent is placed in the adrenal bed. The diaphragm is suture repaired in an airtight manner by a running locking 2-zero polyglactin suture on a CT 1 needle. Freehand laparoscopic suturing and intracorporeal knot tying techniques are used exclusively (fig. 6, B). The pleural cavity is thoroughly irrigated and hemostasis confirmed. Ports are removed under thoracoscopic visualization. In cases 1 and 2 a 34Fr chest tube was inserted through a lateral port and attached to water seal suction. In case 3 no chest tube was used. Instead, each port site was closed with a figure-of-8 2-zero polyglactin suture in the intercostal muscles, which was tied down with the ipsilateral lung maintained in full inhalation by the anesthesiologist, after unclamping the double lumen endotracheal tube. Skin closure was achieved with 4-zero polyglactin subcuticular sutures. RESULTS
Experimental. Transthoracic transdiaphragmatic bilateral nephrectomy was successful in all 8 kidneys (left side 4, right
side 4, table 1). Mean surgical time was 64.3 minutes on the left side and 82.5 minutes on the right side. Inadvertent peritoneotomy occurred during specimen mobilization in 2 instances, which did not compromise intraoperative exposure. Diaphragmatic repair was feasible on each occasion, and no inadvertent injury to adjacent organs was noted. Clinical. Detailed demographic, intraoperative and postoperative data on the 3 clinical cases are presented in table 2. All 3 patients had undergone considerable prior transperitoneal and retroperitoneal open surgery. In the initial 2 cases of solitary adrenal metastasis operating times were lengthy (4.5 and 6.5 hours), with a blood loss of 150 and 500 cc, respectively. The majority of this blood loss was because of peri-adrenal reaction and neovascularity secondary to malignancy. In the third case of an adrenal myelolipoma operating time was 2.5 hours and blood loss was 50 cc. Satisfactory airtight suture repair of the diaphragmatic incision was achieved with freehand laparoscopic suturing and intracorporeal knot tying techniques in all 3 cases, as with increasing experience, a chest tube was not believed to be necessary in the third case (fig. 7). Hemodynamic and capnometric parameters were normal in each case. Postoperatively the ipsilateral hemidiaphragm was documented to have normal respiratory excursions on fluoroscopic examination of the chest in both patients who agreed to undergo the test. During 8, 4 and 2-month followup, respectively, no complications occurred. The adrenal bed appeared free of local recurrence on CT in the 2 patients with adrenal cancer. DISCUSSION
Endoscopic techniques and technology are revolutionizing surgical approaches across virtually all surgical subspecialties, including urology. Initially described in the 1920s, thoracoscopy has evolved from a purely diagnostic tool to complex therapeutic procedures for pulmonary, mediastinal, spinal, esophageal and cardiac pathologies.4 – 6 In 1992 Mack et al first performed thoracoscopic transdiaphragmatic inci-
TABLE 2. Thoracoscopic transdiaphragmatic adrenalectomy: clinical experience Operation date Sex/age (yrs.) Body mass index American Society of Anesthesiologists class Prior abdominal surgery
Case 1
Case 2
Case 3
12/9/99 Male/62 21.4 3 Rt. radical nephrectomy, lt. adrenalectomy Rt. 3.5 Prone 4 150 4.5 25 None 3,300
4/13/00 Male/64 40 3 Lt. radical nephrectomy, rt. partial nephrectomy, cholecystectomy, appendectomy Rt. 2.4 Prone 4 500 6.5 28 None 4,000
6/8/00 Female/20 20 3 Bilat. nephrectomy
Adrenal side Adrenal size (cm.) Pt. position No. ports Blood loss (cc) Total surgical time (hrs.) Diaphragm suturing time (mins.) Inadvertent celiotomy Intraop. intravenous fluids (cc) Pulse rate/min.: Max. 120 136 Min. 76 70 Blood pressure: Max. 180/90 180/100 Min. 120/60 108/64 End tidal carbon dioxide (mm. Hg): Max. 36 40 Min. 25 33 Chest tube Yes, overnight Yes, overnight Resume ambulation (days) 1 1 Resume oral intake (days) 1 1 Morphine sulfate analgesia (mg.) 18 24 Hospital stay (days) 2 2 Convalescence (wks.) 4 4 Postop. diaphragm mobility* N/A Normal Adrenal wt. (gm.) 12 17 Pathological diagnosis Metastatic renal cell Ca Metastatic renal cell Ca Complications None None Followup (mos.) 8 4 * Movement of the postoperative hemidiaphragm was evaluated by fluoroscopic examination of the chest.
Lt. 2.8 Prone 4 50 2.5 18 None 1,500 112 54 190/100 90/50 39 28 No 1 1 38 2 8 Normal 12 Myelolipoma None 2
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FIG. 7. Case 3. Chest x-ray immediately after thoracoscopic left adrenalectomy. Chest tube was not used postoperatively. Left lung is completely expanded without any evidence of pneumothorax.
sional biopsy of the left adrenal gland.7 In 1997 Pompeo et al described transthoracic left adrenalectomy in the porcine model.8 Thoracoscopic repair of the diaphragmatic incision has been performed by endoscopic suturing or staples.8, 9 We recently reported thoracoscopic transdiaphragmatic bilateral nephrectomy in an acute porcine model.10 Thoracic access was obtained with 3 ports and the diaphragm was incised to gain entry into the retroperitoneum in which the feasibility of individual control of the renal artery and vein, and circumferential mobilization of the kidney were demonstrated. The diaphragm was repaired with the Endo Stitch device using continuous suture. In 4 acute pigs mean surgical time was 69.3 minutes for left nephrectomy and 74.3 minutes for right nephrectomy, with a mean blood loss of 18.7 cc. Mean diaphragmatic incision was 7.2 cm. The transthoracic 10 mm. fan retractor could adequately retract the spleen and liver during left sided and right sided nephrectomy, respectively. Intraoperative arterial blood gas parameters were acceptable.10 Based on this porcine study, we proceeded with refining the technique in human cadavers. In our cadaveric study we sought to develop a procedure for thoracoscopic nephrectomy and extrapolate this approach to adrenal surgery as necessary. With the cadaver placed in the lateral position, considerable transthoracic retraction of the liver or spleen was required to achieve the necessary exposure. Nevertheless, the retroperitoneal space could be accessed and developed satisfactorily, and individual control of the renal artery and vein was possible in all 8 procedures. Mean surgical time was 64.3 minutes for left nephrectomy and 82.5 minutes for right nephrectomy. Hilar dissection required approximately a half hour on either side, and no injury to the renal vessels occurred. On average, the diaphragmatic incision was approximately 10 cm., and suture repair of the diaphragm could be performed adequately. Encouraged by our porcine and human cadaveric experience, we proceeded to clinical application. The impetus for exploring the transthoracic approach was
our desire to offer an adequate minimally invasive option to select candidates for adrenalectomy, who have significant concomitant scarring of the intraperitoneal and retroperitoneal spaces. On 2 previous occasions we have performed transperitoneal laparoscopic adrenalectomy in patients who had undergone contralateral open transperitoneal radical nephrectomy followed by staged ipsilateral extraperitoneal open partial nephrectomy for bilateral renal cell carcinoma. Our experience in these patients underscored the technical difficulty of transabdominal laparoscopic adrenalectomy in such a setting. Therefore, we sought to explore the virgin thoracic cavity as a possible access route to the pathological adrenal gland. The thoracoscopic transdiaphragmatic procedure requires a detailed knowledge of thoracic and retroperitoneal anatomy, as well as considerable prior experience with major laparoscopy and open surgery.5, 11 Select double lumen endotracheal intubation with single lung ventilation is imperative. Therefore, the anesthesia team should be thoroughly conversant with double lumen intubation techniques. Adequate deflation of the appropriate lung on clamping the double lumen tube is confirmed by auscultation on 3 separate occasions, including at intubation, after prone positioning and before skin incision.11 A bronchoscope should immediately be available in the operating room, and the double lumen tube is monitored continuously for adequate functioning. For preoperative planning, 3-dimensional CT reconstruction of the adrenal gland with vector projection is useful to plan trocar placement. Because no pneumo-insufflation is used, valved trocars are unnecessary. We used rigid valveless ports (fig. 4, B), which allow free passage of various instruments. Although active retraction of the liver or spleen was necessary in the cadaver in the lateral position, in the clinical application with the patient in the prone position, the gravity induced anterior displacement of the liver or spleen minimized the need for active retraction of these organs. Given the posterior location of the adrenal gland high in the retro-
INITIAL EXPERIENCE WITH THORACOSCOPIC TRANSDIAPHRAGMATIC ADRENALECTOMY
peritoneum, the prone position was advantageous because it allowed a direct approach to the adrenal gland. Real-time ultrasonographic guidance was an indispensable adjunct in precisely planning diaphragmatic incision directly over the adrenal gland. The articulating cartridge vascular stapler significantly expedited control of the main adrenal vein. During diaphragmatic repair, extreme care must be taken to avoid inadvertent needle puncture of the lung, which may result in a bronchopleural fistula. Certain limitations of the transthoracic transdiaphragmatic procedure are obvious.4, 12, 13 This technique would be contraindicated in patients with preexisting cardiopulmonary disease, which precludes single lung ventilation. Prior thoracic surgery with resultant postoperative pulmonary adhesions is another contraindication. Complete familiarity with thoracoscopic techniques is critical, and collaboration with an appropriate minimally invasive thoracic or spine surgeon is recommended. CONCLUSIONS
The thoracoscopic transdiaphragmatic technique is a novel minimally invasive procedure in select patients with surgical adrenal pathology. In patients in whom surgery has not been performed in the abdomen we recommend that laparoscopic adrenalectomy be done with the technically simpler transperitoneal or retroperitoneal approaches. However, in the rare patient in whom prior major abdominal surgery precludes transperitoneal and retroperitoneal laparoscopy, use of the virgin thoracic cavity appears reasonable. Precise anatomical familiarity and considerable experience with thoracoscopic and transabdominal laparoscopy are necessary. Because the learning curve is steep, we believe that prior experience with laparoscopic adrenalectomy in at least 25 to 30 cases is necessary before embarking on the thoracoscopic transdiaphragmatic approach. In addition to the indications aforementioned, in the future, it is feasible that in patients with larger adrenal14 or upper pole renal masses, thoracoscopic and transabdominal laparoscopy could be combined to provide a minimally invasive alternative to open surgical thoracoabdominal incision.
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REFERENCES
1. Gill, I. S., Soble, J. J., Sung, G. T. et al: Needlescopic adrenalectomy: the initial series: comparison with conventional laparoscopic adrenalectomy. Urology, 52: 180, 1998 2. Takeda, M., Go, H., Watanabe, R. et al: Retroperitoneal laparoscopic adrenalectomy for functioning adrenal tumors: comparison with conventional transperitoneal laparoscopic adrenalectomy. J Urol, 157: 19, 1997 3. Sung, G. T., Hsu, T. H. S. and Gill, I. S.: Retroperitoneal approach for adrenalectomy. Unpublished data 4. Dieter, R. A., Jr. and Kuzycz, G. B.: Complications and contraindications of thoracoscopy. Int Surg, 82: 232, 1997 5. Landreneau, R. J., Mack, M. J., Hazelrigg, S. R. et al: Videoassisted thoracic surgery: basic technical concepts and intercostal approach strategies. Ann Thorac Surg, 54: 800, 1992 6. Dexter, S. P., Martin, I. G. and McMahon, M. J.: Radical thoracoscopic esophagectomy for cancer. Surg Endosc, 10: 147, 1996 7. Mack, M. J., Arnoff, R. J., Acuff, T. E. et al: Thoracoscopic transdiaphragmatic approach for adrenal biopsy. Ann Thorac Surg, 55: 772, 1993 8. Pompeo, E., Coosemans, W. and De Leyn, P.: Thoracoscopic transdiaphragmatic left adrenalectomy: an experimental study. Surg Endosc, 11: 390, 1997 9. Fredman, B., Olsfanger, D. and Jedeikin, R.: Thoracoscopic sympathectomy in the treatment of palmar hyperhidrosis: anaesthetic implications. Br J Anaesth, 79: 113, 1997 10. Meraney, A. M., Gill, I. S., Hsu, T. H. et al: Thoracoscopic transdiaphragmatic nephrectomy: feasibility study. Urology, 55: 443, 2000 11. Lieberman, I. H., Salo, P. T., Orr, R. D. et al: Prone position endoscopic transthoracic release with simultaneous posterior instrumentation for spinal deformity: a description of the technique. Spine, 25: 2251, 2000 12. Yim, A. P and Liu, H. P.: Complications and failures of videoassisted thoracic surgery: experience from two centers in Asia. Ann Thorac Surg, 61: 538, 1996 13. Jancovici, R., Lang-Lazdunski, L., Pons, F. et al.: Complications of video-assisted thoracic surgery: a five year experience. Ann Thorac Surg, 61: 533, 1996 14. Hobart, M. G., Gill, I. S., Schweizer, D. et al: Laparoscopic adrenalectomy for large-volume (⬎ or ⫽5 cm) adrenal masses. J Endourol, 14: 149, 2000