G. DE TOMA laporoscopic adrenalectomy

Good morning everyone, I'm going to show you the second clinical case.

It concerns a female patient affected by a left adrenal gland mass.

The patient is 49 years old and her BMI is 27.

Her past medical history includes two cases of TIA,

aneurysm of cervical tract of internal carotid,

aneurysm of left milde cerebral artery,

hypertensive heart disease,

anxio-depressive syndrome.

Her past surgical procedures include

appendectomy and left anasectomy

for endometriosis cyst.

Her medical history includes

hypertension discovered during the first TIA in 2070

so she started to take anti-hypertensive therapy.

But on September 2019

she had the second case of TIA, showing drug-resistant hypertension.

Therefore, she was sent to Rafaela Center of Hypertension, placed in our hospital.

Lab results were an increased free urinary cortisol that was 230 micrograms on 24 hours,

an increased plasmatic cortisol that was 22.1 micrograms on deciliters,

Abdomen MRI showed a left adrenal nodule of about 2 cm, as we can see in the following images.

Adrenal scintigraphy showed hyperfunctioning adenoma of left adrenal gland, as we can see in the following images.

Patient-specific therapy consists of ACE inhibitor, potassium-sparing diuretics, beta-blockers and antidepressants.

Finally, the diagnosis is left adrenal adenoma with hypercortisolism, and our proposed surgical approach is laparoscopic adenolectomy via lateral transperitoneal approach.

Thank you for attention.

Thank you for being with us today. The room is absolutely crowded, but we have to comment in English or in Italian?

Well, we could try a middle way, right?

Ok, let's go. Ok, Professor.

We can also see how they are positioned in the trocha, a kind of parabola.

Yes, that's right.

Here is the xiphoid appendix, then obviously the anterior line.

We are about three fingers below the arch, because obviously when we open the peritoneum it goes down.

you show the others ok and now we enter then then we can go put me well this

transverse hydraulic because it is very high here already these adhesions that are very very high

that generally do not fit this we see well however now we mobilize again because

usually they are lower here they even arrive on the pole on the upper pole of the milza

it could be enough now let's go back to our situation let's see here ok let's release

a little more it seems to me if we do it let's see let's see if it can be enough I don't know because

now we tend to do the preparations those less even for the milsa at least and we try to

to mobilize as little as possible there was an initial phase in which all of us were

led to make great mobilization of the milza then we saw that there were also problems

of repositioning and therefore now we try to mobilize as little as possible ok let's see if it

can be enough for a moment now let's go from here let's see let's see then we establish later here

now always for the younger ones let's go on the splenocleidomers let's go up here we stop

where as even the intervention previously there was the bottom of the stomach and you have to stop

that if not sometimes it can happen that we can cause an ulcer on the bottom of the stomach

nothing special, but obviously a dot must be put, let's go back here, what did you say?

I remind them that in fact the surrhenium, at least the most superficial part, not the middle part of the surrhenium,

are three layers, the glomerular, the reticular, the fasciculate, which produce aldosterone, cortisone and sexual hormones.

in this case the patient was a patient with hypertension so when

patients who are hypertensive are young and generally do not respond to

to the pharmacies before they arrived let's say with a certain delay in the centers

a little specialized in these things and now they begin to arrive before given

also the awareness that has been made with basic medicine because

knowing that about 10 percent from 10 to 12 percent of the population is against

against hypertensive disease no let's say 20 25 percent and of these between 8 and 10 are

non-essential hypertensions at that point you go to look for them a little more now the problem

always arises for the syndromes that can be so-called pre cushing go closer but closer

closer closer because in the cushing I should say pronounce cushing

let's say cushing so they all understand those conclaimed the problem is not

the problem is put instead in the syndromes for cushing that is practically those

who are the patients who are so-called non dipper then in this type of

of patients obviously the intervention must be done because surely at a distance at a distance

of time they will almost certainly have the syndrome and therefore this is a pre-cushion that a few

years ago many schools and on fire you see for a moment if you try to fire please

now yes now it is better here obviously you can see the splenic artery you can see

well now what I always say obviously not to the surgeons obviously already done to those

younger the problem is here it must be solved I put it back for a moment finding perfectly

as I do now the space between the surrhenium and the pancreas because here there is a frank area

that you can very well section so on the one hand the pancreas goes with the artery

that you now see perfectly here here it is and on the other hand there is the kidney with the capsule

and then there is also the surrhenium that now slowly we go to identify a little closer

close here you have to identify this space here this you have to open it let's go back a little

above and now in this area now slowly we do the internet let's go here here you do

it slowly with that so we are doing it in a pretty good way and blood well let's see a little

who sees it first here it is here you have seen it you can see here here it is on the kidney so

This was the plan I was telling you about.

Here I can show you that you can see the lower lower phrenic vein on the left that comes from the other side.

If sometimes you have difficulty identifying the main vein, you can go directly to the lower phrenic

that then obviously joins with the main vein to form the vein that goes on the renal vein.

then now we should find this point calmly so we make it

bloody here we have to open this space slowly and try to identify the vein here now

stay good slowly slowly slowly a moment here with a lot of lightness let's see if we

we divide the vein, this is not needed, slowly, let's try a little bit here, let's try not to

bleed those two vaselines, here, it approaches well here, let me close these

otherwise they bother me, well, a moment, now I go down here, here, let's go into this is the

exact space, slowly from here, this is the colon again, come here, approach here, let's see if you can see

now pull a little bit towards you here be careful without bleeding anything I know that it is not

your fault go little by little behind little by little behind with and this but it seems to me that it beats

to see the vein this is not because this hits this one here you see that this one here is an

artery and let's go up a little more I put my divaricator on the pancreas here

come here come slowly here we go more here so here we must be in proximity let's see here

slowly, close, close, close, let's see here, a moment, eh, slowly, yes, yes, hold, here, good, right there,

close, close, ok, then we are there, eh, you see it, they are not, here, very well, then,

close again, here it is, this is the lower phrenic, which then joins here, and this is the main vein,

then here it is, it approaches that we clean it a little bit to make the cyst pass very

delicately here it is now I can also prepare it a little bit a millimeter more we are

under this is well arenal this here then you can give me cysts at this point let me

clean a little bit here hold a little straight so you give me a little resistance here well

Good, good, like this, perfect, get closer, get closer now, well, give me this cystic, here you can see the renal vein now below, here, yes, you can see it very well, then let's see a little if we can pass, ok, give me, is it loaded? With a little blood reflux, it does nothing, the atheria splenica is close, it's fine, come on, no, it's all reflux, it does nothing, this, let's go back, like this, very well, very well,

flat that we release force here the plan is this here and take off a little here you see a

nice base but this here is felt it was a bit of here you give me then you give me a you give me a

forward above, here, be careful of the parenchyma, well, ok, at this point we go back below, I pull it up a little

, I bring it closer so we are sure not to take anything, let's see first, slowly,

It looks very good, the images are perfect, you can see that the plans are absolutely those anatomically planned.

Excuse me, I did not hear very well.

I said that it looks perfectly good and that the intervention is proceeding great, seeing the plans perfectly identified, very educational, thank you for this.

let's see if you can see if you can see some vases that usually this is the renal artery

this is it you see yes here it is now here there are always some vases that start

from the polar vases and there also these you have to be a little careful because if not

they are the ones that can here they are here that part you see the renal artery is this

and these vaseline start from there, the polar vases that go to

irritate the surrhenium, here it is, this is always the renal artery, here it is, while

this was the splenic, always for the youngest, this one here, slowly, slowly,

We also follow the renal artery in such a way that now the renal artery is cleaned up a little bit, it goes towards the thread and we section the last propagations.

I see that the milza, once it has been unhooked, has no longer given a problem.

The lateral cubit of the patient is at 70 degrees because it is not exactly like for the kidney because we put it at 70 degrees.

now the milza as you have seen we have prepared it here but we have not removed all the

ligaments below because at this point it was too medialized and then there were problems when

the central position was put back down that we have finished that I say slowly I say it to myself

all reflux there is no problem now let's see if there is little little disarray here

and let me see but here little by little here we do not ruin it I try to take let me take this

thing here so I do not ruin it if I do it ok little by little again slowly we take it away

everything is difficult it is all reflux it does not matter at all well we have arrived

from below here it is done then first we put the endo bag and then we go to see a moment

of the operating field and then we close. So this is the body of the pancreas,

this is the splenic artery, this is the pancreas, then it goes down a little, here this is the renal artery,

here where we have prepared, let's see the agraphs, here where there is an agraph, here they are,

see this blue here this is the renal vein you can see the renal vein

you give a wash you can see a polar artery there at the top it seems to me the field is quite

blood then I take it back a little let's also say that the polar one that if here it is here it is the

polar this here this is the renal always for the youngest this is the splenic we go down

down we see the agraf where they are slowly slowly these are the agraf and this blue that

is always seen for the youngest this blue is the renal vein from where the main surrenalic vein

starts then at this point come on let's put a little come on I go yes so let's put here

but you know what the discourse is perhaps a case like this that we have not even used the

vacuum cleaner as I would have well seen they can be superfluous but the agents mostatici

we also need as alibi is in agreement because I always invite to maximum prudence because then

then those who will judge us will probably never have operated on the kidney or pancreas, on the stomach in their lives

and they will tell you why the hemostatic agent was not put and I always put the drainage, always, always, always

okay, it seems to me that everything is ok, then I greet you, thank you for the comment

Thank you professor, there was little to comment on how this intervention was done, I must say, absolutely didactic, it seemed very simple but very simple, it derives from experience and there are a good number of them.

Yes, I agree, medicine sometimes is defensive, but alas they bring us this unfortunately.

Yes, yes, but in fact ...

If there was a case, a case, I mean, serene, it seems to me that it is the one you operated on.

Professor, thank you very much.

The courage of the surgeon is not seen if he leaves a more or less drainage.

I am convinced.

Thank you all, goodbye.

Thank you professor, thank you very much.