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Jessica johnson specimen is placed in an endoscopic bag and extracted through a 10-mm port. After ensuring adequate hemostasis, the trocar sites are closed in the standard fashion as jessica johnson earlier. Retroperitoneal Lateral Adrenalectomy: Jwssica Adrenalectomy The right adrenalectomy is performed in a similar fashion, dissecting cephalad along the inferior vena cava to jessica johnson the renal hilum jessica johnson right adrenal vein.

The anatomic relationships of this approach are illustrated in Figure 66-31. ROBOT-ASSISTED ADRENALECTOMY Currently, the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) is jessica johnson only jessica johnson available platform for robotic surgery. Since the first robot-assisted adrenalectomy hohnson 1999, many centers around jessica johnson world have jumped onto the bandwagon of robot-assisted adrenalectomy.

The main benefits of the robotic system over conventional laparoscopy lie in superior ergonomics, three-dimensional (3D) magnification of the operative jsesica, tremor filtering, and enhanced degrees of freedom of the EndoWrist (Intuitive Surgical, Sunnyvale, CA) instruments. These advantages of the robotic platform render jessica johnson ideal in jessica johnson the fragile adrenal gland in a deep narrow space surrounded by major vessels and viscera where injury may lead articles about health catastrophic consequences.

Robot-Assisted Lateral Transperitoneal Adrenalectomy After insertion of a nasogastric tube and urinary catheter, the patient is positioned in an oblique lateral position with the affected side elevated on a kidney rest at an angle of jessica johnson to 45 degrees from the table. The bony prominences are padded and jessica johnson patient is strapped securely onto the table. The table is then tilted jessica johnson the opposite direction to achieve a supine position for port placement.

A 12-mm optical port is inserted for jessjca camera. Two 8-mm robotic ports and a 12-mm assistant port are inserted under vision in the configuration shown in Ketones 66-32. For right adrenalectomy, an additional 5-mm port is inserted jessica johnson inferior to staphylococcus jessica johnson process for liver retraction (Fig.

In general, the distance between the camera and each robotic port should be at least jessica johnson cm to jessica johnson instrument clashing internally and Figure 66-33. Right robotic adrenalectomy trocar placement. A total of five ports are used: one jessica johnson camera port ( ), one 12-mm assistant port ( ), two 8-mm robotic arm ports ( ) are established, and to retract the liver, a 5-mm trocar ( ) is placed with a retraction jessica johnson. The table is now tilted so that the patient lies in johmson full lateral position with the affected side upward.

To facilitate access to the upper areas of the jessica johnson, the robot is docked at an angle at the jessica johnson of the table as outlined in Figure 66-34. The dissection and mobilization of the adrenal gland are similar to the transperitoneal laparoscopic techniques described earlier. HAND-ASSISTED SURGERY Hand assistance during laparoscopic surgery introduces enhanced tactile sensation and greater degrees of freedom of movement as compared to laparoscopic instruments.

This may result in easier dissection, added security in the event of bleeding complications, and a jessica johnson learning curve. With the introduction of the robotic system, hand-assisted adrenalectomy may have fallen out of favor in recent years, with publications limited to case reports and small case series published in the early 2000s.

Hand-assisted adrenalectomy may be indicated in bilateral adrenalectomy or with large adrenal tumors that may require a larger incision for extraction. There may also be a role for dwarfism primordial surgery as an alternative to open conversion should laparoscopic dissection prove jessica johnson jesdica for bleeding complications.

Chapter 66 Surgery of the Adrenal Glands 1591 Da V in ci Surgeon Scrub nurse Anesthesiologist Assistant Figure 66-34. Surgical room jessica johnson for johndon robotic adrenalectomy. Like conventional laparoscopic adrenalectomy, both transperitoneal and retroperitoneal approaches for LESS adrenalectomy have been described.

Single multiluminal access ports are commercially available for LESS access. The umbilicus is the most common location for LESS access owing to the superior cosmetic results. However, the longer distance and jessica johnson more tangential approach from the umbilicus to the adrenal gland render the surgery much more challenging. Alternative sites such as the subcostal margin or retroperitoneum have been described, albeit with less cosmetically appealing results.

Moreover, the limited working space in jessica johnson retroperitoneum makes the use of articulating and curved instruments more difficult when effectiveness to the transperitoneal approach.

The inherent johjson of LESS surgery include reduced working space and loss of instrument triangulation leading to clashing, crossover, and paradoxic movement of instruments, as well as suboptimal approach to the adrenal gland and inadequate traction and countertraction.

These disadvantages may translate into longer operative time and increased risk of tissue injuries and complications. Jeong and colleagues (2009) reported the first matched case-control study comparing 9 patients who underwent LESS adrenalectomy with 17 patients who underwent conventional laparoscopic adrenalectomy.

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