A four‐step technique of robotic right adrenalectomy: initial experience

Abstract

OBJECTIVE To report a safe, quick and reproducible technique of robotically assisted right adrenalectomy (RRA), developed by assessing the surgical anatomy of the right adrenal gland, its vascularity, and the surrounding structures, through a high definition, magnified three‐dimensional view of the operating field provided by the da Vinci® surgical system (Intuitive Surgical, Sunnyville CA, USA). PATIENTS AND METHODS Four patients had RRA between January and July 2007 at the Vattikuti Urology Institute, for varied indications. We extensively reviewed published anatomical and surgical reports of the anatomy of the region to plan the surgical steps for RRA, careful reconfirming recognized anatomical facts and their probable significance. The surgical steps involved: (i) complete division of the hepatocolic ligament; (ii) definition of the right adreno‐caval junction (ACJ); (iii) division of the right adrenal vein; (iv) dissection and removal of the adrenal gland circumferentially. The surgery was digitally recorded and reviewed. RESULTS All the adrenalectomies were done transperitoneally through five ports, replicating predetermined surgical steps. There were no anaesthesia or surgery related events and no patient required conversion to open surgery. All the patients had an uneventful recovery and were discharged home 0–3 days after RRA. With increasing experience it was possible to reach the ACJ with minimal peripheral dissection. From a lateral approach, we visualized the adrenal vein travelling along the anterior portion of the gland before terminating at the inferior vena cava and the retrocaval location of the medial edge of the adrenal gland. The right adrenal vein (singular or duplicate) was the only surgically significant vessel, as the other vessels encountered were controlled with bipolar diathermy. CONCLUSIONS Robotic assistance facilitated microdissection of fine anatomical planes around the right adrenal gland and provided direct access to the crucial ACJ. This technique permits ligation of the adrenal vein as an initial step, with no need to handle the adrenal gland. In the initial experience with four patients this technique was reproducible, regardless of indication or anatomical variance.

Robot‐assisted adrenalectomy: a technical option for the surgeon?

“…Additionally, the robotic stereotaxic vision can help recognize and control small and numerous vessels. The system allows for work in a deep narrow space surrounded by major vessels and organs, making dissection of the short right adrenal vein otherwise challenging24.…”

WITHDRAWN: The growth of computer-assisted (robotic) surgery in urology 2000–2014: The role of Asian surgeons

“…Eun et al [42] described a four-port "baseball diamond" strategy of port placement for patients undergoing nephroureterectomy to allow instrument access to the ipsilateral upper and lower urinary tract in the same operative session, without repositioning the patient and re-docking the robot. Utilizing the robotic magnification and precision in movement for microdissection of anatomical planes around the adrenal gland, a fourstep technique of robotic right adrenalectomy [43] and synchronous bilateral adrenalectomy [44] were described.…”

Current Trends in Pediatric Minimally Invasive Urologic Surgery

“…The noted benefits were the increased magnification and range of movement as compared to conventional laparoscopy, which aided in the dissection along major vessels and intraabdominal organs, as well as with isolation of the adrenal gland [4,15]. The use of robotic-assisted laparoscopy for adrenalectomy has not yet been described in children.…”