Laparoscopic left adrenalectomy for Conn's disease: transabdominal approach

Pancreatic endocrine tumors (PETs) are uncommon but clinically challenging and fascinating tumors. Small, benign neoplasms are readily curable by surgical resection. This video presents the case of a 40-year-old woman with a tumor at the level of the pancreatic body. The patient’s virtual reconstruction is used during surgery to help the surgeon pinpoint the lesion accurately. A laparoscopic approach is used.

The video "Enucleation of a pancreatic nonfunctioning endocrine tumor localized with intraoperative US and augmented reality" authored by B Dallemagne and J Marescaux is analysed by Dr. A Park, sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

Neuroendocrine tumors (NETs) of the digestive tract are relatively rare. Their annual incidence in the United States is about 3.65 per 100,000 population. The incidence has been rising over time. The laparoscopic approach is an excellent way of treatment for this kind of neoplasm.

A 72-year-old woman was addressed to the endocrinologist for arterial hypertension and US finding of a 5cm nodule in the aortocaval space of the celiac region. The diagnostic workup revealed raised urinary metanephrines. A CT-scan confirmed the US findings, and the nodule was also positive at PET CT-scan. A fine needle biopsy was performed, which was suggestive of a paraganglioma.
Medical treatment with Doxazosine 44mg qd was required for the adequate control of hypertension, and surgical excision was required.
A laparoscopic lateral transabdominal approach was chosen, to displace the hepatoduodenal ligament and allow for a wide access to the inferior vena cava. The operative time was 75 minutes. The patient recovered with no complications and was discharged on postoperative day 3.
Her symptoms recovered and she was found with normal metanephrines at follow-up.

This video demonstrates a routine video-assisted parathyroidectomy. The surgeon uses a 1.5 cm midline neck incision to identify the key structures including the carotid artery, the recurrent laryngeal nerve and the parathyroid adenoma. The middle thyroid vessels are divided and the parathyroid adenoma is mobilized, and the vessels are clipped and divided to remove the adenoma. An intraoperative blood assay confirms that the adenoma has been adequately removed.

This video demonstrates how a slight modification of the standard video-assisted approach for parathyroidectomy can improve the visualization of the operative field.
A slight modification of the standard video-assisted approach for parathyroidectomy can improve visualization of the operative field. Cervical US confirmed the presence of a right superior parathyroid adenoma. The authors make a 2.5cm transverse neck incision 1cm above the sternal notch. In exposing the operative field, they divide the platysma and control the anterior jugular veins. They then dissect and retract the omohyoid muscle to quickly and precisely access the jugulocarotid groove.

Parathyroid surgery has largely benefited from advances in preoperative imaging modalities allowing to determine potential adenomas. Conventionally, ultrasonography and scintigraphy with 99mTc-sestamibi (MIBI) provide sufficient information to guide the surgical procedure. Specific software has been developed at the IRCAD to allow for the 3D reconstruction of the entire cervical structures. The handling of such reconstruction helps to perform a precise preoperative assessment. Arterial reconstruction allows to predict the existence of an arteria lusoria and of a non-recurrent recurrent nerve. In this case, the position of a potential adenoma in relation to the inferior thyroid artery allows to anticipate that it is not an adenoma but a thyroid nodule. A second potential target is visualized inferiorly. These two potential locations will be explored during the video-assisted surgical intervention.

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.