Introduction
Prior to recent advancements in surgical technology, open adrenalectomy was the gold standard for benign and malignant adrenal diseases. With the introduction of laparoscopy, surgeons began to transition to minimally invasive surgery. When compared to open adrenalectomy, laparoscopic adrenalectomy (LA) has been shown to have lower intraoperative blood loss, lower postoperative pain scores, shorter length of stay, and better longer-term cosmesis. On the contrary, laparoscopic surgery offered some unique technical challenges such as a two-dimensional view, difficult to manipulate instruments that lacked multiplanar articulation, and decreased surgeon autonomy. The implementation of robotic-assisted laparoscopic surgery alleviated several of these challenges. Surgeons now have an improved three-dimensional view, articulating robotic arms that mimic human wrist movement, improved surgeon autonomy with operator control of a robotic fourth arm and the operating camera, and better ergonomics.
Robotic surgery has gained significant traction in a variety of urologic procedures, including radical and simple prostatectomy, partial nephrectomy, and recently radical cystectomy. Robot-assisted procedures are beginning to find their place in adrenal surgery. Despite being introduced 20 years ago, robotic adrenalectomy (RA) initially remained underused. This was most likely because of increased operating room cost and lack of access to the surgical robots. ,
In this chapter, we will provide a contemporary overview of benefits and shortcomings of RA by illustrating indications, surgical techniques, and outcomes of the procedure.
Preoperative assessment and indications to robotic adrenalectomy
Surgical indications for RA are identical to those of LA including hormone-secreting tumors, hormone-inactive tumors between 3 and 5 cm that have grown on serial abdominal imaging or similar lesions greater than 5 cm, solitary small pheochromocytomas, and other rare lesions such as myelolipomas ( Fig. 23.1 ).
Currently, there is a lack of high-quality evidence to suggest that RA is appropriate for malignant tumors. Reports in the literature have shown that open adrenalectomy compared to LA has better overall survival and recurrence-free survival. , Absolute contraindications for RA include infiltrative adrenal masses, invasion into surrounding vascular structures or significant involvement of adjacent organs, and large tumors precluding effective use of the robot. General contraindications include inability to safely undergo anesthesia due to other medical comorbidities or active physiologic imbalances such as uncorrected coagulopathy that would place the patient at high risk of mortality.
When a patient is suspected to have a pheochromocytoma, they should undergo confirmatory testing. This can be carried out by measurement of plasma metanephrines, urinary fractionated metanephrines, urinary vanillylmandelic acid (VMA), or plasma VMA, all of which have varying degrees of sensitivity and specificity. Additionally, patients may undergo computer tomography (CT), contrast enhanced CT, or magnetic resonance imaging with use of functional radiotracers such as 123 I-metaiodobenzylguanidine or 111 In-DTPA-pentetreotide. Once confirmed, these patients are placed on an oral adrenergic blockage for 2 weeks preoperatively. During the procedure, the anesthesiologist carefully monitors hemodynamical stability, especially during tumor manipulation.
Surgical technique: Transperitoneal robotic adrenalectomy
Robotic system and instruments
The da Vinci Xi robotic surgical system (Intuitive Surgical Inc., Sunnyvale, CA) is most commonly used. The system consists of an operator-controlled camera and three robotic working arms. Depending on surgeon’s preference, either a 30-degree aimed in a down configuration, or a 0-degree robotic lens is used. The robotic working arms typically consist of a ProGrasp forceps, Hot Shears connected to monopolar electrocautery, and a robotic clip applier. An additional ProGrasp working arm, a monopolar cautery hook, and a Harmonic ACE curved shears (Ethicon Endo-Surgery Inc., Cincinnati, CA) or vessel sealer may be used in certain circumstances. More recently, the SynchroSeal articulating bipolar grasper has been introduced, and it can be used for this procedure. The operator may also elect to use bipolar electrocautery. A bedside assistant port can be placed on the contralateral side for insertion of the Weck Hem-o-lock clip applier (Teleflex Medical) and use of a laparoscopic suction irrigator to improve visualization ( Table 23.1 ).
| Laparoscopic instruments |
|
| Robotic instruments |
|
Port placement
After induction of general anesthesia, the patient is positioned on the operating room table. For right-sided lesions, the patient is moved to the left lateral decubitus position, and for left-sided lesions, the patient is positioned in the right lateral decubitus position. The bed is minimally flexed. The patient’s dependent arm is positioned on an arm board, and the second arm is positioned on a double arm board or resting on top of the dependent arm but separated by a pillow or foam, or at the patient’s side. Great care is taken throughout positioning to ensure all pressure points are padded with pillows and foams.
Optimizing port placement at the beginning of the procedure will ensure an efficient and safe procedure ( Fig. 23.2 ). Anatomical landmarks can be identified and marked with a surgical pen or marker if helpful. Pneumoperitoneum is created by using the Veress technique, or with open Hasson technique if preferred. It is preferable to keep the pneumoperitoneum at 15 mmHg during port placement. The pressure can be subsequently lowered to 10 to 12 mmHg after initiation of the robotic portion of the procedure. The first 8-mm robotic port is then placed superior and lateral to the umbilicus on the ipsilateral side of the operation. The trocar should be inserted at the lateral aspect of the rectus muscle approximately in line with the 11th rib. The robotic camera is then introduced through this first robotic port to ensure appropriate depth of insertion and to allow the surgical team to inspect for any accidental damage to the abdominal organs. The remaining robotic ports are then placed under direct visualization including all remaining 8-mm robotic ports along the lateral aspect of the ipsilateral rectus muscle according to an “in-line” configuration. A 12-mm AirSeal (Conmed) assistant port can be placed in the midline just above the umbilicus. For right-sided RA, an additional 5-mm port can be placed in a sub-xiphoid location for insertion of a laparoscopic locking grasper or Allis clamp to obtain liver retraction. Moreover, the surgeon may elect to insert one additional port in the midline, between the robotic camera port and the upper robotic port cephalad to the umbilicus to provide additional access for assistance.
To avoid instrument clashing during the operation, care should be taken to place robotic ports about 8 cm apart from one another. Additional retraction of surrounding organs can be performed through the assistant port. Docking the Xi robot at the bedside is quite straightforward as the robot can be brought in from different angles with ensuing rotation of the robotic boom to obtain the correct position. The procedure is made of few key steps that are summarized in Table 23.2 .
| Step | Left Side | Right Side |
|---|---|---|
| Adrenal gland exposure |
|
|
| Identification and control of the adrenal vein |
|
|
| Dissection of the adrenal gland |
| |
Adrenal gland exposure
For left-sided adrenalectomies, the surgeon should begin by performing a complete mobilization of the descending colon along the white line of Toldt. The lateral attachments of the spleen to the abdominal cavity are released as well as the splenorenal ligament ( Fig. 23.3 ). At this point the spleen, bowel, and pancreas are reflected medially until the adrenal gland is clearly visualized. Close attention to the pancreatic tail is necessary during this step as it may be confused for the gland itself.
