F. CORCIONE

Again, we're ready for our second case in Monaldi Hospital with Professor Corcione.

Our second case is a 65-year-old female with a VMI of 26.

She has a past medical history of hypertension and no past abdominal surgical history.

A patient referred to our institution with an occasional finding of left adrenal gland adenoma.

She performed the CT scan, which showed the macronodular left adrenal hyperplasia of the adrenal gland of 43 times 36 millimeters.

She also performed a new abdominal US, which confirmed this hypoechoic mass of 4 times 3 centimeters in correspondence with the left adrenal gland.

The patient was then scheduled for a laparoscopic left adrenalectomy.

We are ready for the second operation.

This is the same access than the other one.

the spleen before, and now the left adrenalectomy. As you know, the adrenal gland is a very difficult

exposition in open approach. In the past, sometimes we need about the thoracofenolaparotomy

to have a good vision of the tumor of the adrenal gland. It's behind the spleen, the

the pancreas, so it's not easy in open approach to identify all the anatomical structure.

For the patient position, it's exactly the same, lateral position, with all the advantages

that I described before, and for the trochanter position, it's a little bit different, because

for the sphenotomy, I'm very close to the costal arch, for the adrenalectomy, I'm a

a little bit far the first trocar here and as i suggest you the open various assist technique is

the best this is a patient with the good bmi and i open all the abdominal wall skin aponeurosis

the bubble of the pneumo-peritoneum it show me that i opened the peritoneum and the first troca

lie down very very kindly and now I reach without a risk the abdominal cavity now I

put two trocars and not free if I need I put the third trocar

during the operation for the right hand always ten trocars and for the left

ten five millimeter trocar this is a non-functioning adenoma no no function yes

the our endocrinologists give the laparoscopic indication for the

adenoma about four centimeters starting from from centimeters

meters and put up in the past it was a three now it's a four it's not clear it's not clear

Olympus it's not clear it's not light how is the picture Guido it's correct it's good for me it's

not not good not good we don't see the spleen look we see we are looking now for the splenic

fracture the first step is to mobilize the splenic fracture of the colon and it is difficult

in left hemicolectomy with the patient in a supine position it's easy in this position

in order to have a good exposition of the adrenal gland at the end.

I would like to clarify that a long part of this operation

is for the anatomical dissection of the different structures,

not for the adrenalectomy because for the adrenal gland

operate this type of patient because if there is in that time it's better to

have indication with a functioning gland well it was completely different yes

understand. So this is the genital fascia and I, as in colon rectal surgery, I am going to mobilize

the splenic pressure as I can from the genital fascia. It's very clear here. And the view now

is wonderful so you can see everything better. These are the real advantages of the laparoscopic

approach not minimal abdominal absence but the internal view the possibility to

work with the pleasure of the eyes and what do you think about the posterior

approach I think that's good but I have no experience because I think that it's

good for the bilateral small adrenal pathology so it's not very indicate in

in any case, and I had a good experience with the extraperitoneal approach for the inguinal

hernia in the past.

And for several years I was one of the few surgeons who performed this kind of technique.

It was fantastic, but at the end I understood that it was reserved only for a few hernia,

not for everybody, and it's difficult to understand, difficult to teach, difficult to learn,

so I decided to perform the intraperitoneal approach.

The same concept is for the adrenal gland.

It's something that's difficult to do, difficult to understand, difficult to learn, difficult to teach,

and reserved only for a few cases.

I think that it's useless to continue to perform this approach.

But for bilateral, perhaps a bilateral small pathology is a good indication.

So I go now to the spleen, to mobilize the spleen, and I focus on the genital fascia

in order to avoid to injure the pancreas because of course in attached to the

spleen there is the pancreas I have always my sponge inside in order to help

me to retract and I dissect the splenorenal ligament very close to the

spleen not too close of course because my goal now is to mobilize the spleen

without danger for the pancreas and for the spleen of course and I retract with

the left hand the splenopancreatic how many people are connected with us I know

that they are able to put some question by computer but until this moment I did

It could be an adrenal site.

Now I think that there is here the gland, the adrenal gland is there.

I hope to show you.

There is a lot of fat.

You can imagine this operation by open approach.

have only one iatrogenic splenectomy. This is the mass, the adrenal mass here.

gland, the adenoma. I am not happy about this exposition, so I continue to dissect from

the adrenal gland. Now it's very well the artery. Good. Look.

Yes.

I think the most important lesson that we had by laparoscopic approach is to lean the

the embryological plane in any kind of operation in order to dissect without loss of blood.

Yes. Bloodless operation. I think that is our goal in any case. Of course, it's not

always possible. Of course, we are surgeons. We try to do the best, but sometimes it's

difficult to reach. The stomach is a little bit attached to the diaphragm. I continue my

mobilization because I need to retract naturally the spleen in order to avoid interferences

with the operative field. It's a magnificent view. And now, yes, thank you. It's not for me,

it's from Olympus, Olympus device. I am on the diaphragm. The stomach is there. I try to

mobilize a little bit the left crux from the stomach. It's not useless. And now you see

our landmark of this operation, the phrenic artery and phrenic vein. That is a good landmark to

identify the adrenal vein, as I will show you in a few minutes.

Okay, I think that it's enough and now we go down to look for our

landmarks. I need more space so I mobilize

same step for the left nephrectomy, exactly the same until this moment, okay, clean, and

now we go to look for the masses there, to look for our landmarks, that is the patch,

the adenoma, even if it's not a pheochromocytoma, but the technique is the same, and I try to

to do the same for any kind of surgery the patient is effect and I'm looking

for the adrenal vein to be sure that I identified the adrenal vein I need to

Adrenal and renal vein.

If you have some doubt, you can help by the direction of the diaphragmatic vein, it's

exactly the same as the adrenal vein.

And if you have some doubt again, you have discovered the vein, the renal vein, and to

look for on the other side, the genital vein coming from down.

I don't see where you are.

I don't know.

Okay, it's there, I think.

But it's useless in this moment because it's very clear for us.

and now the first step is to clip this vein and I would like to clarify also

today that this is not a exericis of adenoma it is exericis of all the tumor and so to

To be sure that we remove any part of the adrenal gland, we go on the landmark, the

first one is the vein.

You put just one clip.

I use the precision, this is the advantage of this instrument, bipolare, okay, and now

I go with my dissection to identify the other two landmarks that there are the superior

with the ultra efficient I know no I went out on the ground here it's no good

so I'm bleeding

part of the ground here so I have to go a little bit far to the water clean the

scope yes the big mass is that enoma and adenal gland is surrounding a lot around

the psoas muscle that is, of course, behind the gland, the artery, and the muscle is there.

Okay, so now I have all the landmarks under my eyes.

I don't see exactly where is the adenoma, but I remove anything.

This is perhaps a superior polar artery of the kidney.

It's better to leave in place, of course.

mistake when I try to mobilize the inferior part of the adrenal gland here

with only three trocals.

I don't need the fourth one.

You can see very well the adenoma now, the gland.

Yes, it's there.

I don't touch it.

I don't identify very well the adenoma,

but identify the adrenal space,

identified by the muscle,

by the superior pole of the kidney,

the vein of the renal vein.

image without this laparoscopic vision I don't know how the in open approach

sometimes you need about the thoracofenolaparotomy to have the same

yes to look for the anatomical details but not in this way of course okay the

the last one, between the kidney and the one, two, our landmark.

One, two, three.

Now it's clear, Guido.

Yes, yes.

It's a nice view, and you can see everything, all the landmark.

Do you come to the French Academy of Surgery for the New Year?

Yes.

Yes?

Do.

Okay.

Okay, now I put in the bag the specimen and we take out the specimen through the troca

with a small incision, in this case to perform the laparotomy.

Do you leave a drainage or not?

I suppose I published one complication that we had in a patient with Nagarjuna.

who is coming from Foggia and we performed this technique three days after operation

she go back at home and two months after my friend Tricarico the chief in Foggia performed in the

in an emergency, on a bulbulus of the stomach, and so she had a very high occlusion.

And starting from this experience that we published together, we put the glue after

the operation in this space.

So if I put the glue and I remove all the, yes, I close again this space, it's useless

to the anatomy. Okay. I push a little bit for some seconds. Okay. I finish. I will leave

to the last part of the operation

to Sterex

and Vicky

and question

no

I need now I think

50 minutes to start for the

third operation

ok very well

this is a

compliment it's a pleasure

full operation compliment

thank you thank you so much

see you soon bye bye

bye bye

We can also greet each other in Italian.

Okay.

Ciao, Franco.

I would go to Paris to the Academy for the inauguration of the new year of the French Academy.

I hope so, this year I hope so.

This year I hope so.

All right.

See you tomorrow.

See you tomorrow, maybe we'll meet.

Okay.