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Prevesical genetic paraganglioma and left adrenal mass: laparoscopic resection
Hereditary paraganglioma-pheochromocytoma syndromes are caused by genetic mutations, which lead to the development of multiple neuroendocrine tumors and paraganglioma tumors in the adrenal glands. We report the case of a young patient aged 13 who has been followed up routinely for a familial mutation of the SDHB gene. In this routine follow-up examination, an excessive plasma normetanephrine and norepinephrine secretion is evidenced. A genetic paraganglioma is diagnosed. Imaging studies are conducted to identify its location. A prevesical fixation is demonstrated by both the PET-scan and the MIBG scintigraphy. In this video, a laparoscopic resection of both lesions is demonstrated.
D Mutter, J Marescaux
Surgical intervention
9 years ago
1056 views
7 likes
0 comments
09:10
Prevesical genetic paraganglioma and left adrenal mass: laparoscopic resection
Hereditary paraganglioma-pheochromocytoma syndromes are caused by genetic mutations, which lead to the development of multiple neuroendocrine tumors and paraganglioma tumors in the adrenal glands. We report the case of a young patient aged 13 who has been followed up routinely for a familial mutation of the SDHB gene. In this routine follow-up examination, an excessive plasma normetanephrine and norepinephrine secretion is evidenced. A genetic paraganglioma is diagnosed. Imaging studies are conducted to identify its location. A prevesical fixation is demonstrated by both the PET-scan and the MIBG scintigraphy. In this video, a laparoscopic resection of both lesions is demonstrated.
Laparoscopic en bloc splenopancreatectomy with left adrenalectomy and para-aortic lymphadenectomy
The objective of this video is to present a surgical approach to a left adrenal mass caused by the invasion of a pancreatic lesion. A pulmonary lesion was also found. However, a preoperative biopsy of that lesion was impossible to perform. In order to distinguish the primary origin of this lung lesion, a laparoscopic ‘en bloc’ splenopancreatectomy combined with a left adrenalectomy and a para-aortic lymphadenectomy were planned.
Retrograde distal pancreatectomy with splenectomy is the standard procedure for cancers of the body and tail of the pancreas. In the literature, fewer studies describe the feasibility and the oncological safety of the laparoscopic approach.
This video aims to show the different operative steps of the procedure beginning with laparoscopic adrenalectomy followed by distal pancreatectomy and para-aortic lympadenectomy.
R Romito, L Portigliotti, G Bondonno, M Zacchero, A Volpe
Surgical intervention
11 months ago
1764 views
11 likes
0 comments
13:28
Laparoscopic en bloc splenopancreatectomy with left adrenalectomy and para-aortic lymphadenectomy
The objective of this video is to present a surgical approach to a left adrenal mass caused by the invasion of a pancreatic lesion. A pulmonary lesion was also found. However, a preoperative biopsy of that lesion was impossible to perform. In order to distinguish the primary origin of this lung lesion, a laparoscopic ‘en bloc’ splenopancreatectomy combined with a left adrenalectomy and a para-aortic lymphadenectomy were planned.
Retrograde distal pancreatectomy with splenectomy is the standard procedure for cancers of the body and tail of the pancreas. In the literature, fewer studies describe the feasibility and the oncological safety of the laparoscopic approach.
This video aims to show the different operative steps of the procedure beginning with laparoscopic adrenalectomy followed by distal pancreatectomy and para-aortic lympadenectomy.
Laparoscopic right adrenalectomy for Conn's adenoma using ultrasonic shears
This video very clearly displays all the salient points of the performance of a right adrenalectomy with particular emphasis on the control of the vascular supply.
After controlling the venous landmarks, the authors move to control the main arteries of the adrenal gland. The authors identify the medial and superior pedicles and completely dissect them, gaining control with a one-clip application. The medial pedicle is only 1cm from the aorta. Severe bleeding may ensue, so they control the superior pedicle originating from the diaphragmatic artery with a clip. Identifying these arteries allows the authors to perform a complete removal of the adrenal gland and its surrounding fat. They clearly identify the renal artery, the renal vein just above it, and the inferior pedicle, which is also controlled with a simple clip application. At this point, the gland can be completely mobilized medially and inferiorly.
D Mutter, J Marescaux
Surgical intervention
12 years ago
2575 views
110 likes
4 comments
07:37
Laparoscopic right adrenalectomy for Conn's adenoma using ultrasonic shears
This video very clearly displays all the salient points of the performance of a right adrenalectomy with particular emphasis on the control of the vascular supply.
After controlling the venous landmarks, the authors move to control the main arteries of the adrenal gland. The authors identify the medial and superior pedicles and completely dissect them, gaining control with a one-clip application. The medial pedicle is only 1cm from the aorta. Severe bleeding may ensue, so they control the superior pedicle originating from the diaphragmatic artery with a clip. Identifying these arteries allows the authors to perform a complete removal of the adrenal gland and its surrounding fat. They clearly identify the renal artery, the renal vein just above it, and the inferior pedicle, which is also controlled with a simple clip application. At this point, the gland can be completely mobilized medially and inferiorly.
Pheochromocytoma: laparoscopic right adrenalectomy in a child
In the context of major headaches in a 9-year-old patient whose brother had been operated on for pheochromocytoma, a right adrenal pheochromocytoma with severe arterial hypertension was found.
The given video aims to demonstrate the usefulness of performing a 3D reconstruction of the tumor (using Visible Patient™ 3D reconstruction tool). It is essential to have precise preoperative information and work out a surgical strategy taking into account observed anatomical anomalies, since tumor and/or vascular anatomy may have numerous variations in case of pheochromocytomas.
A reconstruction model can be easily manipulated on a touch screen. It can be oriented in such a way that the angle of view changes allowing for a better understanding of the anatomy, so that an approach to vessels or neighboring organs is easily decided upon. Additionally, the option of adding or deleting this or that anatomical element allows for a simplified visual approach, which usually represents a potential difficulty during dissection.
Finally, the 3D reconstruction of this patient perfectly corresponds to her real anatomy. Thanks to a mere scanning based on the reconstruction, the vascularization mode of the tumor as well as the existence of a hidden part of healthy tissue can be verified.
F Becmeur, A Lachkar, L Soler
Surgical intervention
1 year ago
2738 views
12 likes
0 comments
08:30
Pheochromocytoma: laparoscopic right adrenalectomy in a child
In the context of major headaches in a 9-year-old patient whose brother had been operated on for pheochromocytoma, a right adrenal pheochromocytoma with severe arterial hypertension was found.
The given video aims to demonstrate the usefulness of performing a 3D reconstruction of the tumor (using Visible Patient™ 3D reconstruction tool). It is essential to have precise preoperative information and work out a surgical strategy taking into account observed anatomical anomalies, since tumor and/or vascular anatomy may have numerous variations in case of pheochromocytomas.
A reconstruction model can be easily manipulated on a touch screen. It can be oriented in such a way that the angle of view changes allowing for a better understanding of the anatomy, so that an approach to vessels or neighboring organs is easily decided upon. Additionally, the option of adding or deleting this or that anatomical element allows for a simplified visual approach, which usually represents a potential difficulty during dissection.
Finally, the 3D reconstruction of this patient perfectly corresponds to her real anatomy. Thanks to a mere scanning based on the reconstruction, the vascularization mode of the tumor as well as the existence of a hidden part of healthy tissue can be verified.
Laparoscopic left adrenalectomy for Conn's disease: virtual reality and exposure for vascular approach
This is a very detailed and didactic video demonstrating laparoscopic left adrenalectomy. All the critical steps are presented clearly and the surgical approach is explained at each stage. All the dissection is performed with only a hook cautery and atraumatic graspers. This is an excellent video for laparoscopic surgeons interested in learning adrenalectomy.

Key landmarks in this step are the splenic, adrenal, and renal veins—and the three main arterial pedicles of the latter that supply the left adrenal gland. The steady mobilization of the pancreas with retraction to the left with the spleen allows the authors to identify the renal vein, clear identification of which is essential. Steady dissection of the superior border of the renal vein enables positive identification of the adrenal vein. The authors dissect it circumferentially from the superior border of the renal vein up to the origin of the phrenic vein.
D Mutter, J Marescaux, L Soler
Surgical intervention
12 years ago
3251 views
67 likes
0 comments
14:22
Laparoscopic left adrenalectomy for Conn's disease: virtual reality and exposure for vascular approach
This is a very detailed and didactic video demonstrating laparoscopic left adrenalectomy. All the critical steps are presented clearly and the surgical approach is explained at each stage. All the dissection is performed with only a hook cautery and atraumatic graspers. This is an excellent video for laparoscopic surgeons interested in learning adrenalectomy.

Key landmarks in this step are the splenic, adrenal, and renal veins—and the three main arterial pedicles of the latter that supply the left adrenal gland. The steady mobilization of the pancreas with retraction to the left with the spleen allows the authors to identify the renal vein, clear identification of which is essential. Steady dissection of the superior border of the renal vein enables positive identification of the adrenal vein. The authors dissect it circumferentially from the superior border of the renal vein up to the origin of the phrenic vein.
Laparoscopic adrenalectomy for a bilateral large (10 cm) pheochromocytoma
This is a laparoscopic bilateral adrenalectomy performed for bilateral pheochromocytoma. Although the right gland was 10 cm in size, Prof. Targarona demonstrates skillfully how such a resection can be successfully performed laparoscopically if approached in a stepwise and meticulous fashion. This video is suitable for advanced laparoscopic surgeons.

Once the author identifies the inferior vena cava, he carefully carries out the dissection along its right border to expose the right adrenal vein. He then retracts the adrenal gland in an atraumatic fashion with a peanut gauze, being careful not to rupture the gland. Using gentle retraction with right-angle forceps, the author isolates the right adrenal vein. It is double-clipped then divided. This enables mobilization of the gland. The author then uses the harmonic scalpel to dissect around the gland. The tool can also be used to clip or divide the pedicles often encountered in this step. Once the gland is completely mobilized, one must still handle it with care. The author placed it in an extraction bag.
EM Targarona Soler
Surgical intervention
12 years ago
308 views
34 likes
0 comments
09:26
Laparoscopic adrenalectomy for a bilateral large (10 cm) pheochromocytoma
This is a laparoscopic bilateral adrenalectomy performed for bilateral pheochromocytoma. Although the right gland was 10 cm in size, Prof. Targarona demonstrates skillfully how such a resection can be successfully performed laparoscopically if approached in a stepwise and meticulous fashion. This video is suitable for advanced laparoscopic surgeons.

Once the author identifies the inferior vena cava, he carefully carries out the dissection along its right border to expose the right adrenal vein. He then retracts the adrenal gland in an atraumatic fashion with a peanut gauze, being careful not to rupture the gland. Using gentle retraction with right-angle forceps, the author isolates the right adrenal vein. It is double-clipped then divided. This enables mobilization of the gland. The author then uses the harmonic scalpel to dissect around the gland. The tool can also be used to clip or divide the pedicles often encountered in this step. Once the gland is completely mobilized, one must still handle it with care. The author placed it in an extraction bag.
Minimally invasive right superior parathyroidectomy (MIVAP) for symptomatic primary hyperparathyroidism
This video presents the case of a 62 year-old patient with primary hyperparathyroidism characterized by a PTH which is inconsistent with calcium levels. The diagnosis is confirmed by biological findings before searching for the adenoma inducing this hypersecretion. With the use of current precision imaging techniques, in most cases, the adenoma can be identified and managed surgically. In our team, we perform a 99m Tc-MIBI scintigraphy and a CT-scan allowing for a 3D reconstruction according to the IRCAD protocol. This 3D reconstruction shows the relationships between the adenoma, the inferior thyroid artery, the thyroid gland, and the esophagus, making it possible to perform a video-assisted approach using a scar inferior to 2cm.
M Vix, HA Mercoli, S Tzedakis, J Marescaux
Surgical intervention
2 years ago
1264 views
121 likes
1 comment
08:28
Minimally invasive right superior parathyroidectomy (MIVAP) for symptomatic primary hyperparathyroidism
This video presents the case of a 62 year-old patient with primary hyperparathyroidism characterized by a PTH which is inconsistent with calcium levels. The diagnosis is confirmed by biological findings before searching for the adenoma inducing this hypersecretion. With the use of current precision imaging techniques, in most cases, the adenoma can be identified and managed surgically. In our team, we perform a 99m Tc-MIBI scintigraphy and a CT-scan allowing for a 3D reconstruction according to the IRCAD protocol. This 3D reconstruction shows the relationships between the adenoma, the inferior thyroid artery, the thyroid gland, and the esophagus, making it possible to perform a video-assisted approach using a scar inferior to 2cm.
Video-assisted exploration of the four parathyroid lobes for primary hyperparathyroidism
Background:
The presence of a single parathyroid adenoma accurately located using preoperative imaging is the best indication for minimally invasive surgery when dealing with primary hyperparathyroidism. It is certainly possible to search for several glands that may be suspicious of adenoma, but an extensive experience in video-assisted cervical surgery is required to find the anatomical structures allowing to explore the four parathyroid locations.
Patient and methods:
A 75-year-old obese woman is diagnosed with hypercalcemia, hypophosphoremia, and a high level of PTH during a work-up for joint pain.

Preoperative imaging includes a 3D-reconstructed cervico-mediastinal CT-scan —a computer program developed at the IRCAD-Strasbourg, named VrAnat™, Vr planning™, is used for that purpose. This 3D virtual reconstruction demonstrates three suspicious images respectively located at the right superior parathyroid territory, at the right latero-esophageal area, and at the left inferior parathyroid territory. A video-assisted cervical exploration, guided by this reconstruction, is decided upon. The objective is to find the three suspicious images and to explore the four parathyroid glands.

A 3cm median incision is carried out 2cm above the sternal notch. The right thyrotracheal groove is reached through a dissection performed laterally to the strap muscles and medially to the omohyoid muscle. A complete dissection of the lateral aspect of the thyroid lobe is obtained using blunt dissection and small instruments under endoscopic vision, which is provided by a 30-degree, 5mm scope (Storz, Tüttlingen, Germany). The recurrent laryngeal nerve is identified.

Dissection is now carried on above the inferior thyroid artery. It allows to rapidly identify a superior parathyroid adenoma, which will be resected. It exactly matches with one of the suspicious images.

Dissection is pursued anterior to the intersection between the artery and the nerve so as to find the right inferior parathyroid, which is healthy, underneath the capsule. The latero-esophageal image is now searched for. It is nothing but an anthracosic lymph node.

The left side is approached by dissecting the left jugulocarotid gutter. The left recurrent nerve is identified. The left inferior parathyroid is identified and looks healthy. The suspected image is nothing else but a nodule of the apex of the thyrothymic ligament. The left superior parathyroid, which is healthy, can be finally identified in a strictly orthotopic position, although partially hidden behind a Zuckerkandl’s nodule.

Conclusion:
This cervical exploration has led to the dissection and visualization of the four parathyroid lobes in compliance with classical parathyroid surgery principles.
References:
Berti P, Materazzi G, Picone A, Miccoli P. Limits and drawbacks of video-assisted parathyroidectomy. Br J Surg 2003;90:743-7.

Miccoli P, Materazzi G, Baggiani A, Miccoli M. Mini-invasive video-assisted surgery of the thyroid and parathyroid glands: a 2011 update. J Endocrinol Invest 2011;34:473-80.
M Vix, D Mutter, J Marescaux
Surgical intervention
2 years ago
654 views
71 likes
0 comments
09:39
Video-assisted exploration of the four parathyroid lobes for primary hyperparathyroidism
Background:
The presence of a single parathyroid adenoma accurately located using preoperative imaging is the best indication for minimally invasive surgery when dealing with primary hyperparathyroidism. It is certainly possible to search for several glands that may be suspicious of adenoma, but an extensive experience in video-assisted cervical surgery is required to find the anatomical structures allowing to explore the four parathyroid locations.
Patient and methods:
A 75-year-old obese woman is diagnosed with hypercalcemia, hypophosphoremia, and a high level of PTH during a work-up for joint pain.

Preoperative imaging includes a 3D-reconstructed cervico-mediastinal CT-scan —a computer program developed at the IRCAD-Strasbourg, named VrAnat™, Vr planning™, is used for that purpose. This 3D virtual reconstruction demonstrates three suspicious images respectively located at the right superior parathyroid territory, at the right latero-esophageal area, and at the left inferior parathyroid territory. A video-assisted cervical exploration, guided by this reconstruction, is decided upon. The objective is to find the three suspicious images and to explore the four parathyroid glands.

A 3cm median incision is carried out 2cm above the sternal notch. The right thyrotracheal groove is reached through a dissection performed laterally to the strap muscles and medially to the omohyoid muscle. A complete dissection of the lateral aspect of the thyroid lobe is obtained using blunt dissection and small instruments under endoscopic vision, which is provided by a 30-degree, 5mm scope (Storz, Tüttlingen, Germany). The recurrent laryngeal nerve is identified.

Dissection is now carried on above the inferior thyroid artery. It allows to rapidly identify a superior parathyroid adenoma, which will be resected. It exactly matches with one of the suspicious images.

Dissection is pursued anterior to the intersection between the artery and the nerve so as to find the right inferior parathyroid, which is healthy, underneath the capsule. The latero-esophageal image is now searched for. It is nothing but an anthracosic lymph node.

The left side is approached by dissecting the left jugulocarotid gutter. The left recurrent nerve is identified. The left inferior parathyroid is identified and looks healthy. The suspected image is nothing else but a nodule of the apex of the thyrothymic ligament. The left superior parathyroid, which is healthy, can be finally identified in a strictly orthotopic position, although partially hidden behind a Zuckerkandl’s nodule.

Conclusion:
This cervical exploration has led to the dissection and visualization of the four parathyroid lobes in compliance with classical parathyroid surgery principles.
References:
Berti P, Materazzi G, Picone A, Miccoli P. Limits and drawbacks of video-assisted parathyroidectomy. Br J Surg 2003;90:743-7.

Miccoli P, Materazzi G, Baggiani A, Miccoli M. Mini-invasive video-assisted surgery of the thyroid and parathyroid glands: a 2011 update. J Endocrinol Invest 2011;34:473-80.