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Endocrine surgery

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.


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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
1 year ago
725 views
115 likes
0 comments
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.
PerOral Endoscopic Thyroidectomy (POET), a novel pioneering technique
Thyroid surgery has evolved towards minimally invasive approaches to reduce or prevent cervical scars, which are potential seats for keloidal scarring. Several approaches have been put forward: video-assisted surgery via a reduced cervical scar, transaxillary access with or without robotic assistance, transoral retromandibular approach, retroauricular approach in keeping with a lifting procedure.
In this video, we present the case of an original transoral vestibular approach. This access is exclusively subcutaneous. No cervical scar is necessary. This technique allows for a unilateral or bilateral approach in excellent visualization conditions. Dissection is performed from cranially to caudally with the rapid identification of the inferior laryngeal nerve.
A Anuwong, M Vix, HS Wu
Surgical intervention
1 year ago
3913 views
310 likes
5 comments
25:34
PerOral Endoscopic Thyroidectomy (POET), a novel pioneering technique
Thyroid surgery has evolved towards minimally invasive approaches to reduce or prevent cervical scars, which are potential seats for keloidal scarring. Several approaches have been put forward: video-assisted surgery via a reduced cervical scar, transaxillary access with or without robotic assistance, transoral retromandibular approach, retroauricular approach in keeping with a lifting procedure.
In this video, we present the case of an original transoral vestibular approach. This access is exclusively subcutaneous. No cervical scar is necessary. This technique allows for a unilateral or bilateral approach in excellent visualization conditions. Dissection is performed from cranially to caudally with the rapid identification of the inferior laryngeal nerve.
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
1 year ago
429 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.
Totally endoscopic left hemithyroidectomy: axillary approach for papillary carcinoma, including a critical analysis by M Vix, MD, and point by point answer by Dr. Shah
Introduction:
Endoscopic thyroidectomy is a novel approach used to avoid cervical scar, which represents sequelae of conventional thyroidectomies. This technique is feasible providing equal results under expert hands.
Case presentation:
This is the case of a 20 year-old woman with cervical swelling, a 3 by 3cm solitary nodule in the left thyroid lobe, which was evaluated clinically, radiologically, and withfine-needle aspiration cytology (FNAC). She was diagnosed with a low-risk papillary carcinoma.
Discussion:
The patient underwent an endoscopic transaxillary left hemithyroidectomy under general anesthesia. The recurrent laryngeal nerve and the parathyroid gland were preserved. The patient was discharged with a normal tone on postoperative day 1.
Conclusion:
Endoscopic transaxillary thyroidectomy is a feasible good technique with equal results, which can be considered for patients with small thyroid lesions. Conventional laparoscopic instruments are used without the need for extra instrumentation.

This video is commented upon by Dr. M Vix, MD (University Hospital, Strasbourg, France), providing a comprehensive outline of Dr. Shah's original technique.


Point by point answer by Dr. Shah:

1. Carbon dioxide causing surgical emphysema, especially of an incapacitating nature, has not been experienced since intracavitary pressures are generally maintained at a low level by the almost continuous low-grade suction used throughout the surgery.

2. In our experience, adequate visualization of the thyroid pedicles in close proximity to the gland precludes the need for a deeper and more lateral dissection to identify the jugulocarotid vessels. This potentially decreases the risk of a major vascular mishap.

3. As is the norm with open thyroidectomy, division of the superior thyroid pedicle close to the gland usually does not require the identification of the superior laryngeal nerve.

4. In this approach, the recurrent laryngeal nerve is identified very early on in the dissection. Subsequent dissection is performed in a plane anterior to the visualized nerve, hence preventing any injuries. The recurrent laryngeal nerve is visualized in its entire extent up to Berry's ligament.



AR Shah
Surgical intervention
1 year ago
803 views
113 likes
0 comments
11:09
Totally endoscopic left hemithyroidectomy: axillary approach for papillary carcinoma, including a critical analysis by M Vix, MD, and point by point answer by Dr. Shah
Introduction:
Endoscopic thyroidectomy is a novel approach used to avoid cervical scar, which represents sequelae of conventional thyroidectomies. This technique is feasible providing equal results under expert hands.
Case presentation:
This is the case of a 20 year-old woman with cervical swelling, a 3 by 3cm solitary nodule in the left thyroid lobe, which was evaluated clinically, radiologically, and withfine-needle aspiration cytology (FNAC). She was diagnosed with a low-risk papillary carcinoma.
Discussion:
The patient underwent an endoscopic transaxillary left hemithyroidectomy under general anesthesia. The recurrent laryngeal nerve and the parathyroid gland were preserved. The patient was discharged with a normal tone on postoperative day 1.
Conclusion:
Endoscopic transaxillary thyroidectomy is a feasible good technique with equal results, which can be considered for patients with small thyroid lesions. Conventional laparoscopic instruments are used without the need for extra instrumentation.

This video is commented upon by Dr. M Vix, MD (University Hospital, Strasbourg, France), providing a comprehensive outline of Dr. Shah's original technique.


Point by point answer by Dr. Shah:

1. Carbon dioxide causing surgical emphysema, especially of an incapacitating nature, has not been experienced since intracavitary pressures are generally maintained at a low level by the almost continuous low-grade suction used throughout the surgery.

2. In our experience, adequate visualization of the thyroid pedicles in close proximity to the gland precludes the need for a deeper and more lateral dissection to identify the jugulocarotid vessels. This potentially decreases the risk of a major vascular mishap.

3. As is the norm with open thyroidectomy, division of the superior thyroid pedicle close to the gland usually does not require the identification of the superior laryngeal nerve.

4. In this approach, the recurrent laryngeal nerve is identified very early on in the dissection. Subsequent dissection is performed in a plane anterior to the visualized nerve, hence preventing any injuries. The recurrent laryngeal nerve is visualized in its entire extent up to Berry's ligament.



Is minimally invasive thyroidectomy and parathyroidectomy a real progress?
In this video, Dr. QY Duh briefly describes the main principles of MIVAT and MIVAP and compares the novel techniques used for minimal incision thyroidectomy. He presents the advantages, disadvantages and complications of MIVAP & MIVAT, and outlines current innovative approaches for transaxillary thyroidectomy, e.g. robot-assisted BABA, RATS, facelift thyroidectomy, eMIT, TOVAT, TOVANS, and TOETVA. He demonstrates the key steps in the evolution of MIS thyroidectomy from Kocher, mini-incision, MIVAT, extracervical access to NOTES with main advantages of safety –short incision and no neck incision. Finally, he stresses that minimally invasive thyroid surgery is a real progress to evaluate new operations based on safety and efficacy. However, it may not be a real progress in terms of cost and mortality or morbidity.
QY Duh
Lecture
1 year ago
207 views
21 likes
0 comments
19:41
Is minimally invasive thyroidectomy and parathyroidectomy a real progress?
In this video, Dr. QY Duh briefly describes the main principles of MIVAT and MIVAP and compares the novel techniques used for minimal incision thyroidectomy. He presents the advantages, disadvantages and complications of MIVAP & MIVAT, and outlines current innovative approaches for transaxillary thyroidectomy, e.g. robot-assisted BABA, RATS, facelift thyroidectomy, eMIT, TOVAT, TOVANS, and TOETVA. He demonstrates the key steps in the evolution of MIS thyroidectomy from Kocher, mini-incision, MIVAT, extracervical access to NOTES with main advantages of safety –short incision and no neck incision. Finally, he stresses that minimally invasive thyroid surgery is a real progress to evaluate new operations based on safety and efficacy. However, it may not be a real progress in terms of cost and mortality or morbidity.
Is robotic thyroid surgery a real progress?
In this key lecture, Prof. WY Chung briefly describes his experience and his own technique to perform robotic thyroid surgery. He presents advances in surgical indications and compares the main differences of single incision robotic thyroidectomy and LND with novel techniques, e.g. BABA, facelift thyroidectomy, and transoral periosteal thyroidectomy. He demonstrates the advantages and limitations using research data to describe the future of robotic thyroidectomy as a minimally invasive surgery. He highlights new technologies and newly developed robotic systems with current improvements, which focus on haptic feedback, tactile sensation, and single orifice surgery, which will make AI robotic automation surgery possible in the future.
WY Chung
Lecture
1 year ago
336 views
50 likes
0 comments
13:32
Is robotic thyroid surgery a real progress?
In this key lecture, Prof. WY Chung briefly describes his experience and his own technique to perform robotic thyroid surgery. He presents advances in surgical indications and compares the main differences of single incision robotic thyroidectomy and LND with novel techniques, e.g. BABA, facelift thyroidectomy, and transoral periosteal thyroidectomy. He demonstrates the advantages and limitations using research data to describe the future of robotic thyroidectomy as a minimally invasive surgery. He highlights new technologies and newly developed robotic systems with current improvements, which focus on haptic feedback, tactile sensation, and single orifice surgery, which will make AI robotic automation surgery possible in the future.
Transoral endoscopic thyroidectomy: vestibular approach
In this state-of-the-art lecture, Dr. Anuwong briefly describes the historical developments of thyroidectomy with various approaches, emphasizing natural orifice thyroid surgery with an overview of the first report in animal models, cadaveric models, and human patients in different countries as it happened over time. He describes the key steps, main principles, and complications of TOVANS, ETOA, and TOPOT with their drawbacks. He also introduces his technique of transoral endoscopic thyroidectomy: vestibular approach (TOETVA) with the brief concept of mental nerve injury. He demonstrates his experience in a case report of right lobectomy using TOETVA with postoperative management and impressive results achieved with no infection and no scar. The TOETVA technique proves to be promising as it is safe, feasible, comparable to other approaches, and has excellent cosmetic results.
A Anuwong
Lecture
1 year ago
1507 views
130 likes
1 comment
28:41
Transoral endoscopic thyroidectomy: vestibular approach
In this state-of-the-art lecture, Dr. Anuwong briefly describes the historical developments of thyroidectomy with various approaches, emphasizing natural orifice thyroid surgery with an overview of the first report in animal models, cadaveric models, and human patients in different countries as it happened over time. He describes the key steps, main principles, and complications of TOVANS, ETOA, and TOPOT with their drawbacks. He also introduces his technique of transoral endoscopic thyroidectomy: vestibular approach (TOETVA) with the brief concept of mental nerve injury. He demonstrates his experience in a case report of right lobectomy using TOETVA with postoperative management and impressive results achieved with no infection and no scar. The TOETVA technique proves to be promising as it is safe, feasible, comparable to other approaches, and has excellent cosmetic results.
Ethics and new technology: are we being honest with our patients?
Dr. Angelos delivers an amazing lecture on the following issue: “Ethics and new technology”. He briefly describes progress in the field of surgery and the ethics of innovation. He also outlines the basics of professionalism in medicine, surgeon-patient relationship, and informed consent for innovative operations. He describes the main principles to assess the potential benefits of innovative techniques via the surgeon’s participation in clinical trials or registries. He emphasizes the management of ethical issues via discussions between individual surgeons and patients about the uncertainties of innovations in order to make informed consent a reality.
P Angelos
Lecture
1 year ago
188 views
15 likes
0 comments
22:04
Ethics and new technology: are we being honest with our patients?
Dr. Angelos delivers an amazing lecture on the following issue: “Ethics and new technology”. He briefly describes progress in the field of surgery and the ethics of innovation. He also outlines the basics of professionalism in medicine, surgeon-patient relationship, and informed consent for innovative operations. He describes the main principles to assess the potential benefits of innovative techniques via the surgeon’s participation in clinical trials or registries. He emphasizes the management of ethical issues via discussions between individual surgeons and patients about the uncertainties of innovations in order to make informed consent a reality.
Laparoscopic excision of a celiac paraganglioma
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.
M Lotti, M Giulii Capponi, L Ansaloni
Surgical intervention
1 year ago
796 views
56 likes
0 comments
08:21
Laparoscopic excision of a celiac paraganglioma
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.
Right and left adrenalectomy by transperitoneal approach
In this video, Professor Didier Mutter demonstrates different approaches for laparoscopic adrenalectomy. For a precise and fast dissection, the quality of camera and instruments is essential. Vascular landmarks are of paramount importance, Sometimes, there is a duplication of the adrenal vein, and any mistake in dissection can cause difficulty to control bleeding. 3D reconstruction helps to identify some original anatomical variations. In this lecture, Professor Mutter also discusses the robotic approach used to perform an adrenalectomy with 3D reconstruction for vascular exploration in order to prevent renal vascular damage. The laparoscopic approach is the gold standard for all types of glands. In some complicated cases, the procedure is converted to an open procedure. This does not mean that the technique has failed.
D Mutter
Lecture
2 years ago
2768 views
290 likes
1 comment
18:17
Right and left adrenalectomy by transperitoneal approach
In this video, Professor Didier Mutter demonstrates different approaches for laparoscopic adrenalectomy. For a precise and fast dissection, the quality of camera and instruments is essential. Vascular landmarks are of paramount importance, Sometimes, there is a duplication of the adrenal vein, and any mistake in dissection can cause difficulty to control bleeding. 3D reconstruction helps to identify some original anatomical variations. In this lecture, Professor Mutter also discusses the robotic approach used to perform an adrenalectomy with 3D reconstruction for vascular exploration in order to prevent renal vascular damage. The laparoscopic approach is the gold standard for all types of glands. In some complicated cases, the procedure is converted to an open procedure. This does not mean that the technique has failed.
Laparoscopic posterior retroperitoneoscopic adrenalectomy
In this video, Professor Martin Walz presents the main principles of laparoscopic retroperitoneoscopic adrenalectomy. The patient lies in a prone position with the adrenal gland being approached posteriorly beneath the 12th rib, thereby allowing for a direct access to the retroperitoneum and adrenal gland without the need for intra-abdominal organ mobilization. Carbon dioxide pressure and camera position play a key role for better exposure and imaging. High insufflation pressures in the retroperitoneal space can also reduce troublesome bleeding. This approach remains the best option with no blood loss and reduced postoperative pain, less morbidity, a shorter hospital stay, and an earlier return to normal activities.
M Walz
Lecture
2 years ago
1269 views
97 likes
0 comments
14:34
Laparoscopic posterior retroperitoneoscopic adrenalectomy
In this video, Professor Martin Walz presents the main principles of laparoscopic retroperitoneoscopic adrenalectomy. The patient lies in a prone position with the adrenal gland being approached posteriorly beneath the 12th rib, thereby allowing for a direct access to the retroperitoneum and adrenal gland without the need for intra-abdominal organ mobilization. Carbon dioxide pressure and camera position play a key role for better exposure and imaging. High insufflation pressures in the retroperitoneal space can also reduce troublesome bleeding. This approach remains the best option with no blood loss and reduced postoperative pain, less morbidity, a shorter hospital stay, and an earlier return to normal activities.
Robotic adrenalectomy for left adrenal Conn’s adenoma: live broadcast
According to recent studies, robotic adrenalectomy has proven to be superior to laparoscopic adrenalectomy, with a reduction of blood loss during procedure and a reduced operative time.
The robotic system provides an intraoperative stability to the surgeon, allowing for a perfect handling of sensitive functional adrenal tumors. The main advantage of robotics lies in the ease of dissection, aided by improved visualization, the EndoWrist®, articulated instruments, and reduction of tremors, allowing for more accurate movements.

Indications: hormone-secreting tumors, adrenal masses >5cm, smaller lesions suspicious for malignancy, and lesions increasing in size on serial imaging.
Contraindications: infiltrative adrenal masses and tumors of extremely large size, because the size of adrenal lesions correlates with the potential for adrenal carcinoma.
The da Vinci Robotic Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) and the following robotic instruments are used:30-degree scope, ProGrasp™ forceps, Hot Shears (monopolar curved scissors or a hook), and a Robotic Clip Applier. A monopolar cautery hook and Harmonic ACE® curved shears can also be used when deemed helpful by the surgeon.
Laparoscopic instruments that can be handled by the bedside assistant, a clip applier and a suction device are also used.
CN Tang
Surgical intervention
2 years ago
1672 views
132 likes
0 comments
24:47
Robotic adrenalectomy for left adrenal Conn’s adenoma: live broadcast
According to recent studies, robotic adrenalectomy has proven to be superior to laparoscopic adrenalectomy, with a reduction of blood loss during procedure and a reduced operative time.
The robotic system provides an intraoperative stability to the surgeon, allowing for a perfect handling of sensitive functional adrenal tumors. The main advantage of robotics lies in the ease of dissection, aided by improved visualization, the EndoWrist®, articulated instruments, and reduction of tremors, allowing for more accurate movements.

Indications: hormone-secreting tumors, adrenal masses >5cm, smaller lesions suspicious for malignancy, and lesions increasing in size on serial imaging.
Contraindications: infiltrative adrenal masses and tumors of extremely large size, because the size of adrenal lesions correlates with the potential for adrenal carcinoma.
The da Vinci Robotic Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) and the following robotic instruments are used:30-degree scope, ProGrasp™ forceps, Hot Shears (monopolar curved scissors or a hook), and a Robotic Clip Applier. A monopolar cautery hook and Harmonic ACE® curved shears can also be used when deemed helpful by the surgeon.
Laparoscopic instruments that can be handled by the bedside assistant, a clip applier and a suction device are also used.
Laparoscopic adrenalectomy (update of September 2014 presentation)
Laparoscopic adrenalectomy is an attractive alternative to open surgery in children as it is associated with less operative pain and a rapid resumption of diet and shorter operative time.
The relative contraindications are patients with malignancies which involve lymph nodes, highly vascular pheochromocytomas, and large tumors.
Neuroblastoma, congenital adrenal hyperplasia, pheochromocytomas and adrenal cortical carcinomas are the main indications in children.
The transabdominal lateral approach is more commonly used in the pediatric population.
The tumors are incidental findings and 31% of them are malignant in children.
The various techniques of adrenalectomy, preoperative work-up, and indications are described in this lecture.
D Patkowski
Lecture
2 years ago
1222 views
89 likes
0 comments
16:05
Laparoscopic adrenalectomy (update of September 2014 presentation)
Laparoscopic adrenalectomy is an attractive alternative to open surgery in children as it is associated with less operative pain and a rapid resumption of diet and shorter operative time.
The relative contraindications are patients with malignancies which involve lymph nodes, highly vascular pheochromocytomas, and large tumors.
Neuroblastoma, congenital adrenal hyperplasia, pheochromocytomas and adrenal cortical carcinomas are the main indications in children.
The transabdominal lateral approach is more commonly used in the pediatric population.
The tumors are incidental findings and 31% of them are malignant in children.
The various techniques of adrenalectomy, preoperative work-up, and indications are described in this lecture.
Laparoscopic adrenalectomy
Retroperitoneoscopic adrenalectomy was developed in 1993, initially only for small benign lesions and recently for lesions superior to 5 cm and even malignancies.
This retroperitoneal technique has gained popularity since it allows for a direct access to the gland and prevents unexpected injuries to the intra-abdominal organs.
In this lecture, Dr. Mushtaq outlines the indications for adrenalectomy in children, patient set-up, trocar placement, and operative technique overview. The importance of resecting the gland ‘en bloc’ has been emphasized.
The retroperitoneal approach begins by placing the child in a prone position. The 12th rib, iliac crest, and paravertebral muscles are then marked on the patient. The first incision is made at the lateral border of the lateral vertebral muscles, halfway between the 12th rib and the iliac crest (Heloury et al., 2011).
This lecture was delivered during the pediatric urology course held at IRCAD in March 2016.
I Mushtaq
Lecture
2 years ago
1562 views
143 likes
0 comments
16:41
Laparoscopic adrenalectomy
Retroperitoneoscopic adrenalectomy was developed in 1993, initially only for small benign lesions and recently for lesions superior to 5 cm and even malignancies.
This retroperitoneal technique has gained popularity since it allows for a direct access to the gland and prevents unexpected injuries to the intra-abdominal organs.
In this lecture, Dr. Mushtaq outlines the indications for adrenalectomy in children, patient set-up, trocar placement, and operative technique overview. The importance of resecting the gland ‘en bloc’ has been emphasized.
The retroperitoneal approach begins by placing the child in a prone position. The 12th rib, iliac crest, and paravertebral muscles are then marked on the patient. The first incision is made at the lateral border of the lateral vertebral muscles, halfway between the 12th rib and the iliac crest (Heloury et al., 2011).
This lecture was delivered during the pediatric urology course held at IRCAD in March 2016.
LIVE INTERACTIVE SURGERY: laparoscopic left adrenalectomy for pheochromocytoma
Laparoscopic adrenalectomy was first described by Gagner et al. in 1992. It has become the procedure of choice for most benign adrenal lesions since then because of decreased blood loss, shorter hospital stay, faster recovery, and lower morbidity as compared to open surgery.
The indications for laparoscopic adrenalectomy are the same as for open surgery, except in cases of confirmed adrenocortical carcinomas.
Absolute contraindications for laparoscopic adrenalectomy are as follows: severe cardiopulmonary disease, locally advanced tumors, medically untreated pheochromocytoma, and uncontrolled coagulopathies. This is a live demonstration of a left adrenalectomy recorded during the Minimally Invasive Endocrine Surgery Course, which was held at IRCAD in May 2016.
D Mutter, P Donepudi, J Marescaux
Surgical intervention
2 years ago
3336 views
330 likes
0 comments
28:17
LIVE INTERACTIVE SURGERY: laparoscopic left adrenalectomy for pheochromocytoma
Laparoscopic adrenalectomy was first described by Gagner et al. in 1992. It has become the procedure of choice for most benign adrenal lesions since then because of decreased blood loss, shorter hospital stay, faster recovery, and lower morbidity as compared to open surgery.
The indications for laparoscopic adrenalectomy are the same as for open surgery, except in cases of confirmed adrenocortical carcinomas.
Absolute contraindications for laparoscopic adrenalectomy are as follows: severe cardiopulmonary disease, locally advanced tumors, medically untreated pheochromocytoma, and uncontrolled coagulopathies. This is a live demonstration of a left adrenalectomy recorded during the Minimally Invasive Endocrine Surgery Course, which was held at IRCAD in May 2016.
LIVE INTERACTIVE SURGERY: laparoscopic left adrenalectomy: retroperitoneal access
Retroperitoneal adrenalectomy (posterior approach) provides a direct access to the adrenal gland, hence preventing the risk of injury to intraperitoneal organs. The retroperitoneoscopic approach shortens the mean operative time and it is critical in cases of pheochromocytoma. Consequently, it is the recommended treatment for pheochromocytoma. Blood loss and the convalescence period are also shortened with this approach. The surgical principles of retroperitoneal adrenalectomy according to Professor Martin Walz are as follows: ‘en bloc’ resection, start of dissection with the upper pole of kidney, lower pole of the adrenal gland next, control of the main adrenal vein without clips, and morcellation of the gland if necessary in a bag.
M Walz, P Donepudi
Surgical intervention
2 years ago
1669 views
171 likes
0 comments
39:46
LIVE INTERACTIVE SURGERY: laparoscopic left adrenalectomy: retroperitoneal access
Retroperitoneal adrenalectomy (posterior approach) provides a direct access to the adrenal gland, hence preventing the risk of injury to intraperitoneal organs. The retroperitoneoscopic approach shortens the mean operative time and it is critical in cases of pheochromocytoma. Consequently, it is the recommended treatment for pheochromocytoma. Blood loss and the convalescence period are also shortened with this approach. The surgical principles of retroperitoneal adrenalectomy according to Professor Martin Walz are as follows: ‘en bloc’ resection, start of dissection with the upper pole of kidney, lower pole of the adrenal gland next, control of the main adrenal vein without clips, and morcellation of the gland if necessary in a bag.
Posterior retroperitoneoscopic revision of the right suprarenal space for recurrence of pheochromocytoma
A 36-year-old woman came to the attention of the endocrinologist for a recent onset of headache and tachycardia and an US finding of a 1.8cm nodule in the right suprarenal space.
At age 25, she was submitted to an anterior laparoscopic transperitoneal right adrenalectomy for a 5cm pheochromocytoma. At age 33, she underwent laparoscopic cholecystectomy.
The diagnostic work-up revealed raised urinary metanephrine and normetanephrine and an MRI finding of a 1.5cm nodule in the right suprarenal space, with smaller satellite nodules in the retrocaval space.
A surgical revision of the right suprarenal space was indicated and the posterior retroperitoneal approach was chosen, to warrant better reach of the nodules and allow direct exposure of the retrocaval and retrohepatic spaces.
The operative time was 210 minutes. The patient recovered with no major complications and was discharged on her 4th postoperative day. Her symptoms recovered and she was found with lowered metanephrines at follow-up. An 18-FDG PET-CT scan performed 6 months after the operation showed no abnormal metabolic activity within her body.
M Lotti, M Giulii Capponi, B Carrara, L Moroni, S Cassibba, D Gianola
Surgical intervention
2 years ago
777 views
40 likes
0 comments
16:24
Posterior retroperitoneoscopic revision of the right suprarenal space for recurrence of pheochromocytoma
A 36-year-old woman came to the attention of the endocrinologist for a recent onset of headache and tachycardia and an US finding of a 1.8cm nodule in the right suprarenal space.
At age 25, she was submitted to an anterior laparoscopic transperitoneal right adrenalectomy for a 5cm pheochromocytoma. At age 33, she underwent laparoscopic cholecystectomy.
The diagnostic work-up revealed raised urinary metanephrine and normetanephrine and an MRI finding of a 1.5cm nodule in the right suprarenal space, with smaller satellite nodules in the retrocaval space.
A surgical revision of the right suprarenal space was indicated and the posterior retroperitoneal approach was chosen, to warrant better reach of the nodules and allow direct exposure of the retrocaval and retrohepatic spaces.
The operative time was 210 minutes. The patient recovered with no major complications and was discharged on her 4th postoperative day. Her symptoms recovered and she was found with lowered metanephrines at follow-up. An 18-FDG PET-CT scan performed 6 months after the operation showed no abnormal metabolic activity within her body.
Cystic pheochromocytoma: anatomical landmarks for laparoscopic resection
Surgery for pheochromocytoma is often considered difficult due to local anatomical conditions which are often associated with a hypervascularization and inflammatory reaction. This video demonstrates the case of a patient presenting with a 5cm pheochromocytoma with a necrotic core. Because the patient has a low BMI, the intraoperative anatomy is magnified and all anatomical landmarks are perfectly identified right before dissection. The lesion is eventually embedded in the liver. Its approach and dissection allow to determine the constraints related to adrenal surgery, and particularly regarding the impossibility to manipulate the lesion other than with soft retraction.
D Mutter, J Marescaux
Surgical intervention
3 years ago
2009 views
103 likes
0 comments
15:04
Cystic pheochromocytoma: anatomical landmarks for laparoscopic resection
Surgery for pheochromocytoma is often considered difficult due to local anatomical conditions which are often associated with a hypervascularization and inflammatory reaction. This video demonstrates the case of a patient presenting with a 5cm pheochromocytoma with a necrotic core. Because the patient has a low BMI, the intraoperative anatomy is magnified and all anatomical landmarks are perfectly identified right before dissection. The lesion is eventually embedded in the liver. Its approach and dissection allow to determine the constraints related to adrenal surgery, and particularly regarding the impossibility to manipulate the lesion other than with soft retraction.
Robotic left adrenalectomy for Conn's syndrome
Introduction: Since the first robotic adrenalectomy by Piazza et al. in 1999, using both the ZEUS and AESOP systems, numerous series and case reports have been published describing both left and right adrenalectomies using both transperitoneal and retroperitoneal approaches. These studies demonstrate that the robotic approach is feasible and safe.
Methods: This is the case of a 43-year-old female patient who presented with weakness, muscular cramps and systemic arterial hypertension. Her blood tests revealed a high Na++, low K+, very low renin (inhibited) and high aldosterone dose levels. A CT-scan showed a unique adenoma within 2.6cm at the left adrenal gland. She was diagnosed with Conn’s syndrome.
Results: In this video showing a robotic left adrenalectomy, the patient was placed in a left lateral decubitus, jack-knife position. Four robotic arms were used. Dissection was performed by means of scissors and of a bipolar fenestrated forceps. Operative time took 95 minutes. No measurable bleeding was observed. No UCI stay was necessary and the patient was discharged 24 hours after the intervention.
Conclusion: In this case, adrenal surgery was performed using a robotic approach, which demonstrated that the procedure was feasible, safe, with a low morbidity and a short hospital stay.
Fe Madureira, Fa Madureira, E Parra-Davila, D Madureira
Surgical intervention
3 years ago
1566 views
63 likes
0 comments
08:20
Robotic left adrenalectomy for Conn's syndrome
Introduction: Since the first robotic adrenalectomy by Piazza et al. in 1999, using both the ZEUS and AESOP systems, numerous series and case reports have been published describing both left and right adrenalectomies using both transperitoneal and retroperitoneal approaches. These studies demonstrate that the robotic approach is feasible and safe.
Methods: This is the case of a 43-year-old female patient who presented with weakness, muscular cramps and systemic arterial hypertension. Her blood tests revealed a high Na++, low K+, very low renin (inhibited) and high aldosterone dose levels. A CT-scan showed a unique adenoma within 2.6cm at the left adrenal gland. She was diagnosed with Conn’s syndrome.
Results: In this video showing a robotic left adrenalectomy, the patient was placed in a left lateral decubitus, jack-knife position. Four robotic arms were used. Dissection was performed by means of scissors and of a bipolar fenestrated forceps. Operative time took 95 minutes. No measurable bleeding was observed. No UCI stay was necessary and the patient was discharged 24 hours after the intervention.
Conclusion: In this case, adrenal surgery was performed using a robotic approach, which demonstrated that the procedure was feasible, safe, with a low morbidity and a short hospital stay.
Laparoscopic resection of extra-adrenal paraganglioma
Introduction
Paragangliomas are rare tumors that arise from extra-adrenal chromaffin cells. These tumors arise from dispersed paraganglia that tend to be symmetrically distributed in close relation to the aorta and to the sympathetic nervous system. Paragangliomas have a higher malignancy potential than adrenal pheochromocytomas.
Laparoscopy has the advantage of optical magnification and provides better visualization of small vessels, which allows for meticulous dissection during tumor excision. Laparoscopic resections of such tumors have been described in isolated cases.

Material and methods
We present the case of a 16-year-old female patient who presents with repeated urinary tract infection. An ultrasound demonstrates the presence of a retropancreatic mass. The study was completed by abdominal CT-scan and PET-scan (123-MIBG) where a solid mass of 4.5cm in diameter, homogeneous, encapsulated, without calcifications, located between the third duodenal portion (which is displaced anteriorly) and the inferior vena cava from the level of the right renal vein to the level of the right renal lower pole, is found. The patient presents MIBG (metaiodobenzylguanidine) tracer uptake in the Iodine-123-MIBG scintigraphy, suggesting the diagnosis of adrenal medullary tumor. The hormonal study shows a significant increase in plasmatic normetanephrine (25 times the normal upper limit). A genetic study has found no mutation of the most frequent responsible genes.
Given radiological and hormonal findings, laparoscopic surgery is decided upon with suspected diagnosis of extra-adrenal paraganglioma.

Discussion
In this video, we present a laparoscopic approach to this mass, using an 11mm optical trocar and four 5mm working trocars. As can be appreciated, a very careful dissection is carried out to separate the mass from adjacent structures, dissecting small vessels that drain directly into the inferior vena cava.
Final pathology reports a 5cm retroperitoneal paraganglioma, with vascular invasion. In the immunohistochemical study, cells are positive for Synaptophysin and Chromogranin A. The postoperative course was uneventful, and the patient was discharged on postoperative day 4.
The laparoscopic excision of paraganglioma is safe and feasible, reduces postoperative pain, facilitates early recovery, and shortens hospital stay as compared to open surgery.
As a general conclusion, it is essential to diagnose, localize, and treat paragangliomas, because of the potential cure of symptoms associated with functional tumors, prevention of a lethal hypertensive paroxysm, and early diagnosis of malignant tumors.
Laparoscopy has the advantage of optical magnification and provides better visualization of small vessels, which allows for meticulous dissection during tumor excision. Tumors located between major vessels rarely invade these vessels, but careful and meticulous dissection of the surrounding small vessels is necessary.
The laparoscopic excision of paraganglioma reduces postoperative pain, facilitates early recovery, and shortens hospital stay as compared to open surgery.
C Rodríguez-Otero Luppi, M Rodríguez Blanco, V Artigas Raventós, M Trías Folch
Surgical intervention
4 years ago
969 views
34 likes
0 comments
12:04
Laparoscopic resection of extra-adrenal paraganglioma
Introduction
Paragangliomas are rare tumors that arise from extra-adrenal chromaffin cells. These tumors arise from dispersed paraganglia that tend to be symmetrically distributed in close relation to the aorta and to the sympathetic nervous system. Paragangliomas have a higher malignancy potential than adrenal pheochromocytomas.
Laparoscopy has the advantage of optical magnification and provides better visualization of small vessels, which allows for meticulous dissection during tumor excision. Laparoscopic resections of such tumors have been described in isolated cases.

Material and methods
We present the case of a 16-year-old female patient who presents with repeated urinary tract infection. An ultrasound demonstrates the presence of a retropancreatic mass. The study was completed by abdominal CT-scan and PET-scan (123-MIBG) where a solid mass of 4.5cm in diameter, homogeneous, encapsulated, without calcifications, located between the third duodenal portion (which is displaced anteriorly) and the inferior vena cava from the level of the right renal vein to the level of the right renal lower pole, is found. The patient presents MIBG (metaiodobenzylguanidine) tracer uptake in the Iodine-123-MIBG scintigraphy, suggesting the diagnosis of adrenal medullary tumor. The hormonal study shows a significant increase in plasmatic normetanephrine (25 times the normal upper limit). A genetic study has found no mutation of the most frequent responsible genes.
Given radiological and hormonal findings, laparoscopic surgery is decided upon with suspected diagnosis of extra-adrenal paraganglioma.

Discussion
In this video, we present a laparoscopic approach to this mass, using an 11mm optical trocar and four 5mm working trocars. As can be appreciated, a very careful dissection is carried out to separate the mass from adjacent structures, dissecting small vessels that drain directly into the inferior vena cava.
Final pathology reports a 5cm retroperitoneal paraganglioma, with vascular invasion. In the immunohistochemical study, cells are positive for Synaptophysin and Chromogranin A. The postoperative course was uneventful, and the patient was discharged on postoperative day 4.
The laparoscopic excision of paraganglioma is safe and feasible, reduces postoperative pain, facilitates early recovery, and shortens hospital stay as compared to open surgery.
As a general conclusion, it is essential to diagnose, localize, and treat paragangliomas, because of the potential cure of symptoms associated with functional tumors, prevention of a lethal hypertensive paroxysm, and early diagnosis of malignant tumors.
Laparoscopy has the advantage of optical magnification and provides better visualization of small vessels, which allows for meticulous dissection during tumor excision. Tumors located between major vessels rarely invade these vessels, but careful and meticulous dissection of the surrounding small vessels is necessary.
The laparoscopic excision of paraganglioma reduces postoperative pain, facilitates early recovery, and shortens hospital stay as compared to open surgery.
Robot-assisted left video thoracoscopic partial thymectomy for mediastinal ectopic parathyroid adenoma
This film presents the case of an 85-year-old man who suffered from primary hyperparathyroidism diagnosed on a pathological cervical fracture and elevated laboratory values for parathyroid hormone and calcium. Preoperative localizing studies showed no anomalies on the parathyroid gland. However, a left anterior mediastinal ectopic parathyroid adenoma was found on 99m Tc-MIBI scintigraphy.
Mediastinal parathyroid adenomas can be resected in a minimally invasive fashion via a conventional transcervical approach, or using a video-assisted thoracoscopic resection, allowing for an access to the lower cervical area without the use of a cervicotomy. Robotic-assisted thoracic surgery (RATS) also allows for a better visualization and less instrument crowding, with no difference in clinical results.
Considering the good efficacy and the better chances not to leave tumor tissue missed out during surgery, and the impossibility to install the patient with cervical hyperextension, we decided to perform a robot-assisted thoracoscopy through a left-sided approach, instead of the conventional transcervical approach.
During the intraoperative period, the adenoma was identified, and we did not feel the need to perform PTH assay. There were no complications in the postoperative period. PTH levels reached a normal range after adenoma removal, and the patient was discharged on postoperative day 3. He remains asymptomatic at 3 months after the intervention.
The robotic resection of an intrathymic parathyroid adenoma is a safe and effective alternative to the conventional transcervical approach.
JM Baste, M Dazza, C Peillon
Surgical intervention
4 years ago
1019 views
29 likes
0 comments
06:54
Robot-assisted left video thoracoscopic partial thymectomy for mediastinal ectopic parathyroid adenoma
This film presents the case of an 85-year-old man who suffered from primary hyperparathyroidism diagnosed on a pathological cervical fracture and elevated laboratory values for parathyroid hormone and calcium. Preoperative localizing studies showed no anomalies on the parathyroid gland. However, a left anterior mediastinal ectopic parathyroid adenoma was found on 99m Tc-MIBI scintigraphy.
Mediastinal parathyroid adenomas can be resected in a minimally invasive fashion via a conventional transcervical approach, or using a video-assisted thoracoscopic resection, allowing for an access to the lower cervical area without the use of a cervicotomy. Robotic-assisted thoracic surgery (RATS) also allows for a better visualization and less instrument crowding, with no difference in clinical results.
Considering the good efficacy and the better chances not to leave tumor tissue missed out during surgery, and the impossibility to install the patient with cervical hyperextension, we decided to perform a robot-assisted thoracoscopy through a left-sided approach, instead of the conventional transcervical approach.
During the intraoperative period, the adenoma was identified, and we did not feel the need to perform PTH assay. There were no complications in the postoperative period. PTH levels reached a normal range after adenoma removal, and the patient was discharged on postoperative day 3. He remains asymptomatic at 3 months after the intervention.
The robotic resection of an intrathymic parathyroid adenoma is a safe and effective alternative to the conventional transcervical approach.
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.
G Dapri, L Gerard, M Bortes, V Zulian, GB Cadière
Surgical intervention
4 years ago
1800 views
24 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.
Laparoscopic left adrenalectomy for incidentally detected large adrenal mass
We report the typical case of a young woman presenting with an incidentally detected large left adrenal mass. This was a non-functional tumor incidentally detected during ultrasound scan for other reason. CT-scan confirmed a large adrenal mass with diffuse contrast-enhancement. Blood tests for adrenal function were negative.
A laparoscopic left adrenalectomy was proposed with the main objective to perform a complete left adrenalectomy since the malignant nature of the mass cannot be excluded by available imaging studies. For laparoscopic left adrenalectomy, the patient is in a typical right lateral position. The optical trocar is in the left subcostal position. A 10mm trocar is introduced into the anterior axillary line while other 5 or 10mm trocars are placed laterally under the costal margin.
For the surgical resection of this large tumor, dissection started with the opening of the retroperitoneal space, and with the mobilization of the spleen and tail of pancreas. The renal vein is the secondary key point of dissection, allowing to identify the main adrenal vein. At this point, dissection is continued on the right side of the gland in order to identify the left adrenal artery, up to the inferior phrenic vein, and to the superior adrenal artery. The mass is cleared and removed through the extraction bag.
Editorial note: Luigi Mearini et al. have reported a left adrenalectomy exactly reproducing anatomical and technical principles as detailed on WebSurg.com. This confirms that the technique can be reproduced easily.
L Mearini, E Nunzi
Surgical intervention
4 years ago
4527 views
114 likes
0 comments
13:26
Laparoscopic left adrenalectomy for incidentally detected large adrenal mass
We report the typical case of a young woman presenting with an incidentally detected large left adrenal mass. This was a non-functional tumor incidentally detected during ultrasound scan for other reason. CT-scan confirmed a large adrenal mass with diffuse contrast-enhancement. Blood tests for adrenal function were negative.
A laparoscopic left adrenalectomy was proposed with the main objective to perform a complete left adrenalectomy since the malignant nature of the mass cannot be excluded by available imaging studies. For laparoscopic left adrenalectomy, the patient is in a typical right lateral position. The optical trocar is in the left subcostal position. A 10mm trocar is introduced into the anterior axillary line while other 5 or 10mm trocars are placed laterally under the costal margin.
For the surgical resection of this large tumor, dissection started with the opening of the retroperitoneal space, and with the mobilization of the spleen and tail of pancreas. The renal vein is the secondary key point of dissection, allowing to identify the main adrenal vein. At this point, dissection is continued on the right side of the gland in order to identify the left adrenal artery, up to the inferior phrenic vein, and to the superior adrenal artery. The mass is cleared and removed through the extraction bag.
Editorial note: Luigi Mearini et al. have reported a left adrenalectomy exactly reproducing anatomical and technical principles as detailed on WebSurg.com. This confirms that the technique can be reproduced easily.
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.
G Dapri, V Zulian, M Bortes, P Mathonet, GB Cadière
Surgical intervention
5 years ago
1454 views
13 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.
Typical laparoscopic four-trocar transabdominal adrenalectomy for a 5cm right-sided pheochromocytoma
This is the case of a female patient presenting with a typical 5cm right-sided pheochromocytoma was operated on laparoscopically. Preoperative 3D MRI reconstruction allowed to precisely identify surgical landmarks. The procedure was carried out typically. Four ports were used, and dissection aimed to first mobilize the liver. Control of the main adrenal vein was achieved as the first operative step. Medial, superior, and inferior arteries were dissected and controlled successively. Total freeing of the gland was performed with no manipulation or effraction of the gland's capsule. The postoperative course was uneventful. Small-sized pheochromocytomas are excellent indications for a laparoscopic approach with early control of the vein.
D Mutter, M Vix, L Soler, J Marescaux
Surgical intervention
5 years ago
3132 views
77 likes
0 comments
23:50
Typical laparoscopic four-trocar transabdominal adrenalectomy for a 5cm right-sided pheochromocytoma
This is the case of a female patient presenting with a typical 5cm right-sided pheochromocytoma was operated on laparoscopically. Preoperative 3D MRI reconstruction allowed to precisely identify surgical landmarks. The procedure was carried out typically. Four ports were used, and dissection aimed to first mobilize the liver. Control of the main adrenal vein was achieved as the first operative step. Medial, superior, and inferior arteries were dissected and controlled successively. Total freeing of the gland was performed with no manipulation or effraction of the gland's capsule. The postoperative course was uneventful. Small-sized pheochromocytomas are excellent indications for a laparoscopic approach with early control of the vein.
Video-assisted parathyroidectomy using augmented reality
The effectiveness of preoperative imaging to detect parathyroid adenomas allows for a targeted minimally invasive video-assisted approach. In our department, at the IRCAD, special software is used to virtually reconstruct the neck and its structures from mere CT-scan images of the cervicomediastinal region. This virtual reconstruction helps to precisely define the location of the parathyroid adenoma in relation to the superior part of the sternum, to the inferior thyroid artery and to the thyroid gland, hence guiding the surgeon in the proper identification of anatomical landmarks.
The reconstruction also helps to control the absence of "non-recurrent" recurrent nerves showing the presence of a right brachiocephalic arterial trunk.
M Vix, HA Mercoli, L Soler, J Marescaux
Surgical intervention
5 years ago
1295 views
17 likes
0 comments
06:14
Video-assisted parathyroidectomy using augmented reality
The effectiveness of preoperative imaging to detect parathyroid adenomas allows for a targeted minimally invasive video-assisted approach. In our department, at the IRCAD, special software is used to virtually reconstruct the neck and its structures from mere CT-scan images of the cervicomediastinal region. This virtual reconstruction helps to precisely define the location of the parathyroid adenoma in relation to the superior part of the sternum, to the inferior thyroid artery and to the thyroid gland, hence guiding the surgeon in the proper identification of anatomical landmarks.
The reconstruction also helps to control the absence of "non-recurrent" recurrent nerves showing the presence of a right brachiocephalic arterial trunk.
Robot-assisted left adrenalectomy for Conn's adenoma
As laparoscopy is the standard approach to perform an adrenalectomy, robotic assistance is considered as an effective tool to perform this resection. Surgical steps follow those established for laparoscopy (i.e., mobilization of the spleen and of the pancreas in a patient placed in a lateral position, identification of the renal vein, control and division of the adrenal vein, successive freeing of the medial, external, inferior, and finally posterior aspects of the gland. The sealing devices such as ultrasonic dissectors are well adapted to perform this resection, and to safely control adrenal arteries. Robotic assistance takes full benefit from the degrees of freedom of the tips of the instruments and allows for an easy adrenal gland mobilization and removal.
D Mutter, L Soler, J Marescaux
Surgical intervention
5 years ago
1626 views
23 likes
0 comments
16:19
Robot-assisted left adrenalectomy for Conn's adenoma
As laparoscopy is the standard approach to perform an adrenalectomy, robotic assistance is considered as an effective tool to perform this resection. Surgical steps follow those established for laparoscopy (i.e., mobilization of the spleen and of the pancreas in a patient placed in a lateral position, identification of the renal vein, control and division of the adrenal vein, successive freeing of the medial, external, inferior, and finally posterior aspects of the gland. The sealing devices such as ultrasonic dissectors are well adapted to perform this resection, and to safely control adrenal arteries. Robotic assistance takes full benefit from the degrees of freedom of the tips of the instruments and allows for an easy adrenal gland mobilization and removal.
Primary hyperparathyroidism cure using 3D CT-scan reconstruction
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.
M Vix, J D'Agostino, L Soler, J Marescaux
Surgical intervention
6 years ago
4822 views
6 likes
0 comments
05:46
Primary hyperparathyroidism cure using 3D CT-scan reconstruction
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.
Gasless transaxillary robotic thyroidectomy
Robotic technology has recently been applied to minimally invasive thyroid surgery, with the Da Vinci Surgical System robot (Intuitive Surgical, Inc., Sunnyvale, CA, USA). This system provides a three-dimensional magnified view of the surgical area, hand-tremor filtration, fine-motion scaling, and precise and multiarticulated hand-like motions. Several different approaches have been developed with respect to the location of the incisions and whether or not CO2 insufflation is required to keep the operative space open. Robotic gasless transaxillary thyroidectomy has been used clinically in Korea since late 2007. It has been validated for surgical management of the thyroid gland. The initial cases of robotic thyroidectomy was limited to the well-differentiated thyroid carcinoma with a tumor size of ≤ 2cm without definite extrathyroidal tumor invasion (T1 lesion) or follicular neoplasm with a tumor size of ≤5cm. As robotic experience accumulated, the indication of robotic thyroidectomy to include those patients with T3 or larger size lesions has been expanded. The initial robotic thyroidectomy resembled the endoscopic thyroidectomy using two separate incisions, axilla and anterior chest wall. With sufficient experience, the anterior chest wall incision was removed and developed a less invasive transaxillary single-incision robotic thyroidectomy. This procedure has reduced the dissection and the surgical invasiveness with similar surgical outcomes.
Until now, more than 100 cases of compartment-oriented modified radical neck dissection with acceptable postoperative outcomes and excellent cosmesis had been also performed with the Da Vinci robotic system.
WY Chung
Lecture
6 years ago
1710 views
6 likes
0 comments
31:16
Gasless transaxillary robotic thyroidectomy
Robotic technology has recently been applied to minimally invasive thyroid surgery, with the Da Vinci Surgical System robot (Intuitive Surgical, Inc., Sunnyvale, CA, USA). This system provides a three-dimensional magnified view of the surgical area, hand-tremor filtration, fine-motion scaling, and precise and multiarticulated hand-like motions. Several different approaches have been developed with respect to the location of the incisions and whether or not CO2 insufflation is required to keep the operative space open. Robotic gasless transaxillary thyroidectomy has been used clinically in Korea since late 2007. It has been validated for surgical management of the thyroid gland. The initial cases of robotic thyroidectomy was limited to the well-differentiated thyroid carcinoma with a tumor size of ≤ 2cm without definite extrathyroidal tumor invasion (T1 lesion) or follicular neoplasm with a tumor size of ≤5cm. As robotic experience accumulated, the indication of robotic thyroidectomy to include those patients with T3 or larger size lesions has been expanded. The initial robotic thyroidectomy resembled the endoscopic thyroidectomy using two separate incisions, axilla and anterior chest wall. With sufficient experience, the anterior chest wall incision was removed and developed a less invasive transaxillary single-incision robotic thyroidectomy. This procedure has reduced the dissection and the surgical invasiveness with similar surgical outcomes.
Until now, more than 100 cases of compartment-oriented modified radical neck dissection with acceptable postoperative outcomes and excellent cosmesis had been also performed with the Da Vinci robotic system.
Posterior approach to laparoscopic left adrenalectomy including virtual reality simulation
Since M. Gagner published the first case of a transperitoneal laparoscopic adrenalectomy in 1992, the laparoscopic adrenalectomy has gradually become the standard operation for removing adrenal tumors. Compared to a traditional adrenalectomy, a laparoscopic adrenalectomy has a number of advantages, including less blood loss, a shorter hospital stay, a quicker recovery, and fewer complications. There are many ways to approach the adrenal gland laparoscopically, such as by a lateral transperitoneal approach, anterior transperitoneal approach, lateral retroperitoneal approach, and posterior retroperitoneal approach. This video shows a posterior left adrenalectomy using virtual reality simulation.
M Walz, L Soler, J Marescaux
Surgical intervention
7 years ago
1849 views
30 likes
1 comment
25:24
Posterior approach to laparoscopic left adrenalectomy including virtual reality simulation
Since M. Gagner published the first case of a transperitoneal laparoscopic adrenalectomy in 1992, the laparoscopic adrenalectomy has gradually become the standard operation for removing adrenal tumors. Compared to a traditional adrenalectomy, a laparoscopic adrenalectomy has a number of advantages, including less blood loss, a shorter hospital stay, a quicker recovery, and fewer complications. There are many ways to approach the adrenal gland laparoscopically, such as by a lateral transperitoneal approach, anterior transperitoneal approach, lateral retroperitoneal approach, and posterior retroperitoneal approach. This video shows a posterior left adrenalectomy using virtual reality simulation.