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복강경을 이용한�최소 침습 부신절제술�

외과 과장 류예빈

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Introduction

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Minimally Invasive Surgery (MIS)

  • Laparoscopic surgery
    • Decreased pain
    • Rapid return to normal activity
    • Lower rate of post-op wound infection

​

  • Considerations
    • Patient selection
    • Conversion to open surgery
    • Good-quality equipment
    • Adequate training

​

​

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Endoscopy imaging system

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Endoscopy tower

  • Monitor
  • Camera control box
  • Light source
  • Insufflator
  • Data recording device

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Laparoscopic Technique

  • Pneumoperitoneum
    • Establishment of a working space
    • Insufflating CO2 into the abdominal cavity
    • Intraabdominal pressure; 8 – 10 mm Hg

​

  • Laparoscopic trocar
    • Laparocope port
    • Instrument port

​

​

​

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Adrenal mass

  • Differential diagnosis
    • Nodular hyperplasia
    • Adenoma
    • Adrenocortical carcinoma
    • Granuloma
    • Metastatic neoplasia
    • Pheochromocytoma

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Adrenal mass

  • Functional
    • Surgical or medical treat
  • Non-functional
    • Assess for signs of malignancy �; consider adrenalectomy

Assess for sign of malignancy:

          • Greatest diameter of mass > 2 cm
          • Invasion into vessels or adjacent organs
          • Evidence of metastasis

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Material and methods

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Patient Positioning

  • The surgeon and surgical assistant should stand on the side of the table
    • Faces the animal’s ventral abdomen
  • Endoscopic tower placed directly opposite the surgeon on the other side of the patient

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Patient Positioning

  • “Semi‐sternal” position
    • Tilt the dog toward the side on which the surgeon is standing
    • Created using a mechanical tilt table
    • Surrounding organs to fall ventrally away from the adrenal gland

​

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Portal Position and Creation of Working Space

  • 3 or 4 port
    1. 2 to 5 cm lateral to the umbilicus
    2. 5 to 10 cm cranial to and 5 to 8 cm lateral to the subumbilical port on the left side in a location just caudal to the costal arch
    3. 5 to 10 cm caudal and 5 to 8 cm lateral to the subumbilical port in the lower left quadrant

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Surgical Technique

  • Dissection
    • Right-angle forceps
    • Maryland jaw forceps
    • Endo-peanut
  • J-hook electrosurgery or bipolar sealing device

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Surgical Anatomy

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Results

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Case 1

  • Signalment
    • 10-year-old, 3.8 kg, SF, Maltese

​

  • Physical examination
    • HR 210, BP 155

​

  • CC
    • PU/PD

​

  • U/A
    • USG 1.011 (1.015 – 1.045)

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Case 1

​

Result

Reference range

Glu

101

75 - 128 (mg/dL)

TP

6.9

5 - 7.2 (g/dL)

ALB

3.3

2.6 - 4 (g/dL)

GLB

3.6

2.5 - 4.5 (g/dL)

ALP

2080

47 - 254 (U/L)

ALT

172

17 - 78 (U/L)

AST

31

17 - 44 (U/L)

GGT

19

5 - 14 (U/L)

T-BIL

0.5

0.1 - 0.5 (mg/dL)

BUN

21.3

9.2 - 29.2 (mg/dL)

Crea

0.58

0.4 - 1.4 (mg/dL)

Ca

12.9

9.3 - 12.1 (mg/dL)

Phos

5.2

1.9 - 5 (mg/dL)

​

Result

Reference range

pH

7.36

7.31-7.46

pCO2

46

27 – 50 (mmHg)

pO2

39.1

24 – 48 (mmHg)

Na+

156

145 – 151 (mmol/L)

K+

4.3

3.9 – 5.1 (mmol/L)

Ca2+

1.36

1.16 – 1.4 (mmol/L)

Cl-

113

110 - 119 (mmol/L)

HCT

42.8

37.3 – 61.7 (%)

RDW

20.5

13.6 – 21.7 (%)

RETIC

45.6

10.0 – 110.0 (K/uL)

WBC

7.68

5.05 – 16.76 (K/uL)

PLT

451

148 – 484 (K/uL)

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Case 1

RK

Liver

Rt. Adrenal gland

Rt. Adrenal gland

CdVC

RK

Liver

1.7 * 1.9 cm

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Case 1

T

V

T

V

T

V

* T: tumor, V: Caudal vena cava

R

L

Cr

Cd

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Case 1

  • ACTH ; 6.9 – 20.9 (ug/dl)
  • LDDST; 5.7 - 6.3 - 8.7 (ug/dl)

​

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Case 1

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Case 1

  • Laparoscopic Rt. adrenalectomy
  • Semi-sternal position
  • 3port

RK : Right Kidney, RV: Renal vein, CVC : Caudal vena cava�L : Liver, ★ : Rt. adrenal mass

RK

L

CVC

RK

L

RV

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Case 1

RK

L

P

CVC

RK

L

RK : Right Kidney, RV: Renal vein, CVC : Caudal vena cava�L : Liver, ★ : Rt. adrenal mass, P : Phrenicoabdominal vein

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Case 1

  • Adrenocortical adenoma, completely excised

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Case 2

  • Signalment
    • 8-year-old, 4.3 kg, CM, Pomeranian
  • Clinical sign
    • None
    • Incidental finding
    • BP; normal range

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Case 2

​

Result

Reference range

Glu

94

75 - 128 (mg/dL)

TP

6.2

5 - 7.2 (g/dL)

ALB

3.1

2.6 - 4 (g/dL)

GLB

3.1

2.5 - 4.5 (g/dL)

ALP

169

47 - 254 (U/L)

ALT

33

17 - 78 (U/L)

AST

29

17 - 44 (U/L)

GGT

6

5 - 14 (U/L)

T-BIL

0.4

0.1 - 0.5 (mg/dL)

BUN

12.5

9.2 - 29.2 (mg/dL)

Crea

0.9

0.4 - 1.4 (mg/dL)

Ca

11.9

9.3 - 12.1 (mg/dL)

Phos

3.8

1.9 - 5 (mg/dL)

​

Result

Reference range

pH

7.45

7.31-7.46

pCO2

35.6

27 – 50 (mmHg)

pO2

46.8

24 – 48 (mmHg)

Na+

151

145 – 151 (mmol/L)

K+

4.2

3.9 – 5.1 (mmol/L)

Ca2+

1.27

1.16 – 1.4 (mmol/L)

Cl-

116

110 - 119 (mmol/L)

HCT

49.8

37.3 – 61.7 (%)

RDW

20.3

13.6 – 21.7 (%)

RETIC

44.5

10.0 – 110.0 (K/uL)

WBC

7.83

5.05 – 16.76 (K/uL)

PLT

354

148 – 484 (K/uL)

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Case 2

1.38 * 1.61 cm

0.33 cm

Rt. Adrenal gland

Rt. Adrenal gland

CdVC

Ao

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Case 2

* T: tumor, V: Caudal vena cava

R

L

Cr

Cd

T

V

T

V

T

V

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Case 2

  • Laparoscopic Rt. adrenalectomy
  • Lateral recumbency; 30 degree tilt
  • 2 portal application

RK

L

CVC

RK

L

RK : Right Kidney, RV: Renal vein, CVC : Caudal vena cava�L : Liver, ★ : Rt. adrenal mass, P : Phrenicoabdominal vein

L

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Case 2

RK

L

P

CVC

CVC

RK

P

RK : Right Kidney, RV: Renal vein, CVC : Caudal vena cava�L : Liver, ★ : Rt. adrenal mass, P : Phrenicoabdominal vein

CVC

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Case 2

  • Adrenocortical carcinoma

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Case 3

  • Signalment
    • 8-year-old, 4.5 kg, SF, Pomeranian
  • Clinical sign
    • None
    • Incidental finding

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Case 3

​

Result

Reference range

Glu

103

75 - 128 (mg/dL)

TP

6.6

5 - 7.2 (g/dL)

ALB

3.8

2.6 - 4 (g/dL)

GLB

2.8

2.5 - 4.5 (g/dL)

ALP

153

47 - 254 (U/L)

ALT

39

17 - 78 (U/L)

AST

36

17 - 44 (U/L)

GGT

10

5 - 14 (U/L)

T-BIL

0.4

0.1 - 0.5 (mg/dL)

BUN

14

9.2 - 29.2 (mg/dL)

Crea

1.04

0.4 - 1.4 (mg/dL)

Ca

12.5

9.3 - 12.1 (mg/dL)

Phos

4.1

1.9 - 5 (mg/dL)

​

Result

Reference range

Na+

149

145 – 151 (mmol/L)

K+

3.8

3.9 – 5.1 (mmol/L)

Cl-

118

110 - 119 (mmol/L)

HCT

58

44 – 57 (%)

RDW

14.8

14 – 17 (%)

WBC

7.4

56 – 12 (K/uL)

PLT

292

200 – 460 (K/uL)

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Case 3

1.21 * 1.61 cm

0.34 cm

Lt. Adrenal gland

Lt. Adrenal gland

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Case 3

T

P.V

T

P.V

T

P.V

* T: tumor, P.V: Phrenicoabdominal vein

R

L

Cr

Cd

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Case 3

  • Laparoscopic Lt. adrenalectomy
  • Left lateral-ventral oblique position
  • 4port

RK : Right Kidney, RV: Renal vein, CVC : Caudal vena cava�L : Liver, ★ : Rt. adrenal mass, P : Phrenicoabdominal vein

LK

LK

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Case 3

  • Adrenocortical adenoma

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Discussion

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Laparoscopic Adrenalectomy

  • Short- and long-term outcomes were similar
  • Hypotension occurred less frequently with laparoscopy than with laparotomy
    • Surgical time, CO2 insufflation of the peritoneum, positioning
  • Surgical time was significantly shorter in the LA group

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Open adrenalectomy vs. Laparoscopic adrenalectomy

6

3.67

2.25

1.17

(n=3)

(n=7)

(n=3)

(n=4)

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Patient Selection

  • Rule out vascular invasion
  • Lesions up to 5-6cm maximal diameter have been resected
  • Smaller lesions(1-4cm) be attempted early in the learning curve
  • Right-sided lesions may be more challenging to resect than left-sided lesion
  • Cranial pole lesions are simpler to resect

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Laparoscopic surgery indications

  • Laparoscopic biopsy
    • Liver, pancreas, kidney

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Laparoscopic surgery indications

  • Laparoscopic ovariectomy
  • Laparoscopic cholecystectomy

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Conclusion

  • Laparoscopic surgery
    • Decreased pain
    • Rapid recovery

​

  • Laparoscopic Adrenalectomy
    • Safe procedure
    • Rule out vascular invasion
    • Adrenal mass size
      • Less than 4 cm

​