In this video, a case of Cushing's syndrome due to 3 cm sized left adrenal mass treated by left robotic adrenalectomy (RA) is presented. A 33-year old female patient who was diagnosed with Cushing's syndrome at another center due to the presence of a 3 cm sized left adrenal mass lesion was referred to our institution for robotic surgery. Preoperative pituitary magnetic resonance imaging (MRI) was within normal limits. Abdominal ultrasound the MRI showed a 3 cm sized left adrenal lesion. Serum cortisol level was elevated the ACTH level was decreased. Serum adrenalin the noradrenalin levels were within normal limits. Before admission, the patient had a 6 month history of obesity, impaired glucose intolerance, menstrual dysfunction, hirsutism, acne, abdominal striae the depression. Her body mass index was 34.6 kg/m2. A transperitoneal RA was performed using the da Vinci-S four-arm surgical robot (Intuitive Surgical, Sunnyvale, CA, USA).
While the patient is under general anesthesia the in a 45° left flank position, a 12-mm port is inserted initially above the lateral to the umbilicus at the lateral border of the abdominal rectus muscle, using the Hasson technique. After this, the, remaining trocars are inserted under visual guidance. Overall, five abdominal trocars are placed, including the fourth robotic arm. Robotic instruments including a 30° down scope (camera arm), Hot Shears (monopolar curved scissors) for the right hand (1st arm), Maryland bipolar forceps for the left hand (2nd arm) the ProGrasp forceps for the 4th arm are used. Although the use of the 4th arm is not necessary in all cases, its use facilitates the procedure by providing the advantage of additional assistance the tissue handling. Intra-abdominal CO2 pressure is set to 15 mmHg. Initially, a white line of Toldt is incised, the descending colon is taken down the then the kidney is identified. Thereafter, Gerota's fascia is opened the the renal vein is isolated. Location of the adrenal gland is identified the fat tissue overlying the adrenal gland is removed, thus exposing the adrenal mass. All of the borders of the adrenal mass are meticulously dissected. The artery the vein of the adrenal gland are identified. Small sized arteries can be cauterized by Maryland bipolar forceps the cut with monopolar curved scissors. However, endoclip application (Weck Hem-o-Lok clips, Teleflex Medical) is required in order to ligate the larger sized adrenal vein. A vessel sealing device might be useful in dissecting the adrenal border in order to prevent unnecessary bleeding. Due to the lack of tactile sensation in robotic surgery, it is important to apply minimal traction or minimal pressure on the adrenal mass in order to prevent capsular perforation the bleeding. Following completion of adrenalectomy, the excised specimen is inspected in the abdomen before it is placed in an endobag. The specimen is also inspected for clean borders the margins in addition to possible capsular perforation.
Console time was 1.5 hours the estimated blood loss was 50 cc. Postoperative care was uneventful the the patient was discharged 3 days post-operation. The pathology report revealed a primary pigmented nodular adrenal cortical hyperplasia with an adenoma size of 3x3x2 cm the an adrenal gland size of 6x3x3 cm.
Submitted: 1 April, 2015
Accepted: 2 April, 2015
Published: 2 April, 2015
Abdullah Erdem Canda
CONFLICTS OF INTEREST:
The authors declare no conflicts of interest.