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Viola ZULIAN

Saint-Pierre University Hospital
Brussels, Belgium
MD
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Transumbilical single access laparoscopic right adrenalectomy with 1.8mm epigastric trocarless grasping forceps
Background: Single access laparoscopic adrenalectomy has been reported in supine and prone patient positioning. The authors report the technique with the patient in supine position, with the umbilicus as access site, and with all adopted material as reusable.

Video: A 43-year-old woman was admitted to the hospital for symptomatic primary hyperaldosteronism. A right-side adrenal adenoma was diagnosed, and surgery was proposed. The patient was placed in a supine position with a mild semi-lateral left-sided decubitus. The technique was performed using an 11mm reusable trocar to accommodate a 10mm, 30-degree rigid and regular length scope, in addition to curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany). The right liver lobe was retracted using the 1.8mm trocarless grasping forceps according to DAPRI (Karl Storz Endoskope), inserted percutaneously under the 12th right rib. The procedure started with the adhesiolysis between the hepatic surface and right Gerota’s fascia. Then, after having identified the adrenal gland, it was dissected and the inferior adrenal arteries and veins were clipped between 5mm Hem-o-lok® clips (Teleflex Medical, Research Triangle Park, NC, US). The middle adrenal vein was clipped as well using the 5mm Hem-o-lok® ligation systems. Once the specimen was completely mobilized, a plastic bag (used for suction drain) was custom-made and introduced into the abdomen through the 11mm trocar. The specimen was removed transumbilically, and the procedure finished with the closure of the access site by absorbable figure of 8 sutures.

Results: Laparoscopic time was 98 minutes, estimated blood loss was 20cc, and the final scar length was 16mm. The patient was discharged from the hospital after 2 days.

Conclusions: Transumbilical single access laparoscopic right adrenalectomy is feasible and safe. With this technique, the cost of the procedure is not increased, the final scar length is minimal, and the working triangulation is established intrabdominally as well as externally.
Surgical intervention
5 years ago
1857 views
25 likes
0 comments
06:24
Transumbilical single access laparoscopic right adrenalectomy with 1.8mm epigastric trocarless grasping forceps
Background: Single access laparoscopic adrenalectomy has been reported in supine and prone patient positioning. The authors report the technique with the patient in supine position, with the umbilicus as access site, and with all adopted material as reusable.

Video: A 43-year-old woman was admitted to the hospital for symptomatic primary hyperaldosteronism. A right-side adrenal adenoma was diagnosed, and surgery was proposed. The patient was placed in a supine position with a mild semi-lateral left-sided decubitus. The technique was performed using an 11mm reusable trocar to accommodate a 10mm, 30-degree rigid and regular length scope, in addition to curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany). The right liver lobe was retracted using the 1.8mm trocarless grasping forceps according to DAPRI (Karl Storz Endoskope), inserted percutaneously under the 12th right rib. The procedure started with the adhesiolysis between the hepatic surface and right Gerota’s fascia. Then, after having identified the adrenal gland, it was dissected and the inferior adrenal arteries and veins were clipped between 5mm Hem-o-lok® clips (Teleflex Medical, Research Triangle Park, NC, US). The middle adrenal vein was clipped as well using the 5mm Hem-o-lok® ligation systems. Once the specimen was completely mobilized, a plastic bag (used for suction drain) was custom-made and introduced into the abdomen through the 11mm trocar. The specimen was removed transumbilically, and the procedure finished with the closure of the access site by absorbable figure of 8 sutures.

Results: Laparoscopic time was 98 minutes, estimated blood loss was 20cc, and the final scar length was 16mm. The patient was discharged from the hospital after 2 days.

Conclusions: Transumbilical single access laparoscopic right adrenalectomy is feasible and safe. With this technique, the cost of the procedure is not increased, the final scar length is minimal, and the working triangulation is established intrabdominally as well as externally.
Single incision transumbilical laparoscopic bilateral inguinal hernia repair (TEP)
Background: Laparoscopic repair of inguinal hernia by preperitoneal mesh placement (TEP) has been popularized. Recently, with the advent of single incision transumbilical laparoscopy, this procedure has to be considered because it allows to place a big mesh with a very small final scar, which is also cosmetically acceptable.

Video: A 48-year-old male was admitted to hospital for right direct and indirect and left direct inguinal hernia. A single-incision transumbilical bilateral TEP was proposed. The patient was placed in a supine position with his legs straight. The surgeon stood first on the patient’s left and on the patient’s right later on in the procedure. The natural umbilical scar was incised and the rectus fascia on the left side was opened. A purse-string suture using Vicryl 1 was placed starting at a 9 o’clock position. An 11mm reusable metallic trocar was introduced behind the left rectus muscle into the preperitoneal space. A 0-degree, normal length and rigid scope was advanced into the 11mm trocar and the preperitoneal space was insufflated. This space was dissected using the optical system, first on the right side, and then on the left side. At the time of hernia sac retraction, a monocurved reusable grasping forceps IV according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) was introduced inside the purse-string suture, at a 9 o’clock position, parallel to the 11mm trocar. The bilateral hernia sac was reduced, the peritoneal sheet was retracted, and the spermatic elements skeletonized. Two 15cm (latero-lateral) by 10cm (medial cranio-caudal) by 8cm (lateral cranio-caudal) polypropylene meshes (Bard Davol Inc., Warwick RI, US) were introduced through the 11mm trocar. Both meshes were adequately positioned using the monocurved grasping forceps, placing the lateral corner anteriorly to the peritoneal sheet and the medial corner underneath the pubic bone. Meshes were not fixed and the space was desufflated under view.

Results: Operative time was 67 minutes and the final incision length was 12mm. Postoperative pain was controlled by paracetamol (4 g/day) and the patient was discharged after 24 hours.

Conclusions: Single incision transumbilical bilateral TEP makes sense because it allows to place two big meshes using a very small final scar. This treatment allows to increase abdominal trauma reduction, already obtained through conventional multitrocar laparoscopic TEP.
Surgical intervention
5 years ago
4186 views
77 likes
0 comments
07:50
Single incision transumbilical laparoscopic bilateral inguinal hernia repair (TEP)
Background: Laparoscopic repair of inguinal hernia by preperitoneal mesh placement (TEP) has been popularized. Recently, with the advent of single incision transumbilical laparoscopy, this procedure has to be considered because it allows to place a big mesh with a very small final scar, which is also cosmetically acceptable.

Video: A 48-year-old male was admitted to hospital for right direct and indirect and left direct inguinal hernia. A single-incision transumbilical bilateral TEP was proposed. The patient was placed in a supine position with his legs straight. The surgeon stood first on the patient’s left and on the patient’s right later on in the procedure. The natural umbilical scar was incised and the rectus fascia on the left side was opened. A purse-string suture using Vicryl 1 was placed starting at a 9 o’clock position. An 11mm reusable metallic trocar was introduced behind the left rectus muscle into the preperitoneal space. A 0-degree, normal length and rigid scope was advanced into the 11mm trocar and the preperitoneal space was insufflated. This space was dissected using the optical system, first on the right side, and then on the left side. At the time of hernia sac retraction, a monocurved reusable grasping forceps IV according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) was introduced inside the purse-string suture, at a 9 o’clock position, parallel to the 11mm trocar. The bilateral hernia sac was reduced, the peritoneal sheet was retracted, and the spermatic elements skeletonized. Two 15cm (latero-lateral) by 10cm (medial cranio-caudal) by 8cm (lateral cranio-caudal) polypropylene meshes (Bard Davol Inc., Warwick RI, US) were introduced through the 11mm trocar. Both meshes were adequately positioned using the monocurved grasping forceps, placing the lateral corner anteriorly to the peritoneal sheet and the medial corner underneath the pubic bone. Meshes were not fixed and the space was desufflated under view.

Results: Operative time was 67 minutes and the final incision length was 12mm. Postoperative pain was controlled by paracetamol (4 g/day) and the patient was discharged after 24 hours.

Conclusions: Single incision transumbilical bilateral TEP makes sense because it allows to place two big meshes using a very small final scar. This treatment allows to increase abdominal trauma reduction, already obtained through conventional multitrocar laparoscopic TEP.
Transumbilical single access laparoscopic left adrenalectomy for symptomatic pheochromocytoma
Background: Single access laparoscopy has been reported for adrenal gland surgery. This technique can also be applied for patients presenting non-small lesions and symptomatic diseases such as pheochromocytoma.

Video: A 17-year-old woman was admitted to hospital for severe headaches, palpitations, and tachycardia along with tremulousness, dizziness, and vomiting. A symptomatic left-side single location adrenal pheochromocytoma was diagnosed and a transumbilical single access laparoscopic left adrenalectomy was proposed. The patient was placed in a semi-lateral right-sided decubitus. The technique was performed using an 11mm reusable trocar to accommodate a 10mm, 30-degree rigid and regular length scope in addition to curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany). The procedure started with the opening of the splenocolic ligament and, after mobilization of the splenopancreatic block medially, the adrenal lesion was demonstrated. Probably due to the size of the lesion, only two main adrenal vessels were found: vein and mid-artery. Both vessels were dissected and divided between 5mm non-absorbable clips. The specimen was retrieved transumbilically in a custom-made plastic bag.

Results: Laparoscopic time was 129 minutes, estimated blood loss 20cc, and the final scar length measured 16mm. The symptomatic status of the patient was resolved immediately. The patient was discharged from the intensive care unit after 3 days and from the hospital after 6 days.

Conclusions: Transumbilical single access laparoscopic left adrenalectomy for symptomatic pheochromocytoma is feasible and safe. In young ladies, it offers an excellent cosmetic result, avoiding abdominal trauma.
Surgical intervention
5 years ago
1502 views
14 likes
0 comments
07:29
Transumbilical single access laparoscopic left adrenalectomy for symptomatic pheochromocytoma
Background: Single access laparoscopy has been reported for adrenal gland surgery. This technique can also be applied for patients presenting non-small lesions and symptomatic diseases such as pheochromocytoma.

Video: A 17-year-old woman was admitted to hospital for severe headaches, palpitations, and tachycardia along with tremulousness, dizziness, and vomiting. A symptomatic left-side single location adrenal pheochromocytoma was diagnosed and a transumbilical single access laparoscopic left adrenalectomy was proposed. The patient was placed in a semi-lateral right-sided decubitus. The technique was performed using an 11mm reusable trocar to accommodate a 10mm, 30-degree rigid and regular length scope in addition to curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany). The procedure started with the opening of the splenocolic ligament and, after mobilization of the splenopancreatic block medially, the adrenal lesion was demonstrated. Probably due to the size of the lesion, only two main adrenal vessels were found: vein and mid-artery. Both vessels were dissected and divided between 5mm non-absorbable clips. The specimen was retrieved transumbilically in a custom-made plastic bag.

Results: Laparoscopic time was 129 minutes, estimated blood loss 20cc, and the final scar length measured 16mm. The symptomatic status of the patient was resolved immediately. The patient was discharged from the intensive care unit after 3 days and from the hospital after 6 days.

Conclusions: Transumbilical single access laparoscopic left adrenalectomy for symptomatic pheochromocytoma is feasible and safe. In young ladies, it offers an excellent cosmetic result, avoiding abdominal trauma.