Laparoscopic surgery for adrenal disease

In 1901, German surgeon Kelling first used Nize cystoscopy for abdominal examination. With the improvement and development of endoscopy, laparoscopic surgery has been widely used in the diagnosis and treatment of general surgery, obstetrics and gynecology and urology. In recent years, the development of laparoscopic surgery in urology has been even more encouraging. It has the advantages of small damage, less postoperative pain, quick recovery, etc. It is more and more accepted and applied by patients and urologists. In the 1960s, laparoscopy was only used for the diagnosis of patients with intra-abdominal cryptorchidism and pseudo-hermaphroditism and high ligation of spermatic vein. In 1979, Wickman used laparoscopic retroperitoneal ureterolithotomy. In 1985, Eshghi used laparoscopic pelvic heterotopic renal incision. In the 1990s, Glayman used laparoscopic nephrectomy and Parra used abdominal cavity. Mirror pelvic lymphadenectomy and biopsy. At present, laparoscopic surgery has been widely used in the treatment of various diseases of urology, such as complete seminal vesicle resection, ureteral obstruction after gynecological surgery, bladder diverticulectomy, renal cyst drainage, renal cyst decompression, Postoperative renal cyst drainage, urinary incontinence bladder neck suspension, ureteropelvic ureteroplasty, ureteral anti-reflux surgery, nephrectomy, prostatectomy and even radical prostatectomy. In 1992, Gagner used laparoscopic surgery for 3 cases of adrenalectomy, which opened up a new era of laparoscopic surgery in adrenal surgery. Laparoscopy has been used to treat primary aldosteronism, adrenal pheochromocytoma, Cushing's syndrome, adrenal adenoma, adrenal cysts with the accumulation of experience and instrumental improvements. Brunt reported that only 9 patients with 33 adrenal diseases had to undergo traditional surgery. Foreign data showed that about 60% of adrenal diseases can be replaced by laparoscopy instead of traditional surgery. Laparoscopy has broad prospects in the field of adrenal surgery. Treating the disease: adrenal crisis Indication Laparoscopic surgery for adrenal diseases applies to: 1. Aldosteronoma Due to the small volume of adenoma (<2cm), the patient is thin and easy to operate, especially suitable for laparoscopic surgery. 2. Cushing's syndrome adenoma or adrenal hyperplasia caused by the Cushing's syndrome side of the adrenal gland, partial resection of the contralateral adrenal gland. 3. Excision of adrenal cysts. 4. No functional incident tumor (diameter <5cm), myeloid lipoma. 5. Adrenal pheochromocytoma In the past, pheochromocytoma was considered to be unsuitable for laparoscopic treatment, mainly due to long operation time, severe blood pressure fluctuation during operation, and multiple blood vessels on the surface of the tumor, which may cause complications such as intraoperative hemorrhage, shock, and myocardial infarction. With the accumulation of experience, the gradual improvement of instruments and equipment, laparoscopic surgery has been used for <6cm adrenal pheochromocytoma. Contraindications 1. Systemic bleeding disorders. 2. Patients with acute abdominal inflammation. 3. The general condition is difficult to tolerate the operator. 4. Poor lung function (due to artificial pneumoperitoneum, the diaphragm will move up, affecting lung function). 5. Too obese people have difficulty in surgery, and beginners should not use it. 6. Malignant, multiple, ectopic and pheochromocytoma with a diameter of >6 cm should not be treated with laparoscopic surgery. Mainly due to high technical requirements, long operation time, patient intolerance and complex anatomy of the tumor and surrounding organs. Preoperative preparation 1. Preoperative preparation for hypercortisolism (1) Acetyl cortisone 100 mg is usually administered intravenously 12 h and 24 h before surgery. (2) Patients with high blood sugar and urine glucose should control their blood sugar and urine sugar in the normal range to avoid poor wound healing. (3) Cortical adenoma was given ACTH 25mg ~ 50mg 2 days before surgery, intramuscular injection, 2 times a day. (4) Correct the disorder of water and electrolyte balance. (5) Applying broad-spectrum antibiotics before surgery. (6) Correct the negative nitrogen balance to supply sufficient energy or intravenously supplement enough protein and multivitamins. There is a significant negative nitrogen balance, 25 mg of phenylpropionate, twice a week. 2. Preoperative preparation of primary aldosteronism (1) Limited sodium supplementation: The sodium salt can be limited to 5g per day, and the oral potassium salt is 6-9g per day, which can reach the normal range within 1 to 2 weeks. (2) spironolactone 80mg ~ 120mg, 3 times a day, 1 ~ 2 weeks, blood potassium rose to 5 ~ 6mmol / L, nocturia normal or basic normal, urinary potassium is less than 20mmol / L, feasible surgical treatment . (3) Improve cardiac function: If there is abnormal heart rhythm and abnormal electrocardiogram, it may be treated with dilated blood vessels and antihypertensive drugs. (4) Give effective antibiotics 2 to 3 days before surgery. 3. Preoperative preparation of adrenal pheochromocytoma and adrenal medulla hyperplasia (1) Use -blocker benzyl bromide 10-30 mg, 2 to 3 times a day, or prazosin 0.5 to 2 mg, 3 times a day. Use calcium channel blocker nifedipine 10 ~ 30mg, 3 times a day. If necessary, use -blocker propranolol (propranolol), dose 10 ~ 30mg, 6 ~ 8h once orally, so that the heart rate is reduced to 80 ~ 100 times per minute. (2) Expansion therapy: At the same time as the -blocker, intravenously enter a sufficient amount of colloid or crystalloid to supplement the insufficient blood volume. Before surgery, the crystal solution can be supplemented with 1000-2000ml and whole blood 400ml. (3) Preoperative anesthesia is scopolamine. (4) Corticosteroid spare. (5) routine use of antibiotics before surgery to eliminate infection in the body. Surgical procedure There are two ways of laparoscopic adrenalectomy: 1 peritoneal approach after abdominal incision; 2 artificial lacunar approach after peritoneal. Both paths have their own advantages and disadvantages, and the path used generally depends on the surgeon's operating experience. 1. Transperitoneal approach (1) In the supine position, the affected side is raised by 30-35°, and the operating bed can be rotated to keep the affected side high. (2) Establish artificial pneumoperitoneum: lift the ventral wall of the umbilicus, and use the Veress needle to puncture the abdominal cavity at the lower edge of the umbilicus. At this time, the water droplets at the end of the needle rapidly flow into the abdominal cavity due to negative pressure in the abdomen, and the CO2 gas abdomen machine and the needle tail Connect, slowly inject CO2 into the abdomen, if there is no discomfort, the injection speed can be accelerated until the abdominal swelling, the percussion liver dullness disappears, and CO2 is injected into 4L, and the intra-abdominal pressure is 1.7-2.0 kPa (13-15 mmHg). (3) Propose the Veress needle, make a small transverse incision at the puncture point, directly under the anterior sheath of the rectus abdominis, the size of which can be entered by the Trocar trocar, the incision is too small, the insertion of the trocar is difficult, and there is too much air leakage. may. The trocar can be inclined downward by 45°, and the abdominal cavity has obvious decompression feeling. The needle core is taken out and placed in the laparoscope, and the pneumoperitone machine is connected to observe whether there is abdominal injury or bleeding. (4) Under laparoscopic direct vision, a small incision is made to the front of the affected side of the umbilical cord and the xiphoid junction, and the second trocar is placed, and the position is changed to tilt it to the healthy side by 60-70°. Place the third trocar parallel to the midline of the lateral abdominal wall and the umbilicus. If necessary, place the 4th and 5th cannula at the midpoint of the anterior superior iliac spine and the umbilical line, the midpoint of the xiphoid and the umbilical line. needle. Different parts can be selected according to the type of surgery, and 5mm, 10mm, 12mm trocars can be placed according to the operation needs. (5) Due to the positional relationship, the intestines are all sunken downward, and the colonic hepatic or spleen spleen can be seen. After the incision, the peritoneum enters the right or left retroperitoneal space. 1 left adrenalectomy (1) The peritoneum was cut along the lateral side of the descending colon, and the spleen of the colon above the transverse colon, down to the sigmoid colon, and the colon was separated inward and downward. The left mesenteric membrane can also be directly cut. (2) Cut the perirenal fascia, separate it to the renal hilum along the anterior surface of the left kidney, and expose and dissociate the left renal vein. (3) Find the left adrenal central vein along the upper edge of the left renal vein. After free, use three titanium clips to stop the blood. The central adrenal vein was cut off and two titanium clips were retained near the heart. (4) Look for the adrenal gland upper, middle and lower arteries, cut off after the titanium clamp is clamped, or cut off in the free side electrocoagulation. (5) Check the adrenal gland fossa and completely electrocoagulate to stop bleeding. Place the adrenal gland in a special bag. If the volume is not large, it can be placed in the condom and removed from the body through the umbilicus channel. Pull out the cannula and suture the incision. 2 right adrenalectomy (1) Incision of the peritoneum along the right side of the ascending colon, pushing the colonic liver flexion to the medial side, or cutting the right hepatic collateral ligament along the transverse colonic hepatic curvature, pushing open the omentum, transverse colon, and pulling the liver upward. (2) Cut the perirenal fascia and carefully free the front and outer sides of the vena cava at the upper edge of the renal hilum. There is a dense adipose tissue on the inner side of the upper pole of the kidney. The brown-yellow adrenal gland can be seen with a slight separation. The outer side and the long sides of the two sides are loosely attached to the adipose tissue. The adrenal central vein is separated and the titanium clip is cut off, and the proximal end is retained. 2 titanium clips. (3) dissect and free the upper, middle and lower adrenal arteries. After the titanium clamp is clipped, it can be cut off with an ultrasonic knife. (4) Thoroughly check the adrenal fossa and stop bleeding, and put the glands into the bag and remove them from the umbilicus channel. (5) Pull out the cannula and suture the incision. 2. Retroperitoneal approach (1) The lateral position of the affected side is upward, the waist bridge is padded from the waist, and the anterior line and the posterior line of the waist are marked with gentian violet. (2) Make a 1cm long incision at 2cm on the midline of the sacral line. After cutting the skin, use the cervical probe to separate the muscle layer to the back fascia. The Veress needle punctures the lumbar fascia. When the puncture, there is a clear breakthrough into the retroperitoneal space. The needle should not be too deep. (3) Turn on the pneumoperitoneum, inject CO2 gas, inflate about 2L, pull out the Veress needle when the pressure reaches 2kPa (15mmHg), insert a 10mm trocar in the original dilation channel, exit the needle, and put it into the laparoscope. And vertically separate a small cavity. If the trocar is not easy to enter the retroperitoneal space, the skin can be cut open, the vascular clamp is separated, the finger enters the retroperitoneal space, and the trocar is used to enter the retroperitoneal space. (4) Insert a balloon catheter from the trocar, inject 500-700ml of water, expand the balloon for 5 minutes, then pull out the water bag, then laparoscopically inflated, the air pressure is maintained at 2kPa (15mmHg), and the pre-heated laparoscopic device is placed. In the casing, under the monitoring, two trocars are placed in the first channel of the front line and the rear line. When the surgical procedure is difficult to expose the adrenal gland, the fourth trocar can be placed, usually at the proximal end of the anterior iliac crest. (5) Insert the speculum on the middle line of the squat, set the electric hook and shear on the channel on the right hand side, and insert the separation clamp and the attracting rod on the channel on the left hand side. (6) Observe the retroperitoneal space, cut the fascia with tension under direct vision, push open the adipose tissue, identify the edge of the lumbar muscle, release it to the lateral side of the head, and open the perirenal fascia and adipose tissue from the lateral posterior. The remaining steps are the same as the transperitoneal route. complication 1. Gastric ventral complications The incidence of this complication is about 3.5%, and most of the risks are not significant. The main reason is that the Veress needle is improperly placed or the pneumoperitoneum malfunctions, resulting in increased intra-abdominal pressure. (1) Subcutaneous emphysema: often due to the Veress needle not penetrating into the abdominal cavity and the leakage of CO2 gas into the subcutaneous space at the entrance of the Trocar needle. A wide range of subcutaneous emphysema, gas can be diffused up to the chest, neck, mediastinum, facial caused by pneumothorax, mediastinal emphysema and even hypercapnia, then laparoscopic surgery should be stopped immediately. If the Veress needle penetrates into the preperitoneal space, the distance between the skin, muscle layer and peritoneum increases after inflation, which makes the Trocar needle difficult to enter the abdominal cavity. In this case, extraperitoneal fat is often seen during laparoscopic observation. The best treatment for this complication is to withdraw the gas in the pre-peritoneal space. The Trocar needle can be placed by skin incision or the operation piece can be placed directly into the pre-peritoneal space. The peritoneum can be lifted with a grasping forceps. Penetrate into the abdominal cavity. (2) Tension pneumoperitoneum: caused by the obstruction of the pneumoperitoneum, the intra-abdominal pressure is continuously increased, the blood volume is reduced, the diaphragmatic muscle activity is limited, and the lungs are ventilated, thereby causing hypotension, pneumothorax or mediastinal emphysema. Prevention of such complications occurs before the establishment of pneumoperitoneum, should carefully check whether the operation of the pneumoperitoneum is normal, and maintain the intra-abdominal pressure of 1.7 ~ 2.0kPa (13 ~ 15mmHg). If there is a pneumoperitoneum, stop the laparoscopic operation immediately, slowly withdraw the gas, and decide whether to stop or continue the laparoscopic surgery depending on the patient's condition. (3) chronic arrhythmia: including sinus bradycardia, atrioventricular block and so on. Often due to abdominal swelling and CO2 gas stimulation of the peritoneum caused by vagus nerve reflex, preoperative atropine can prevent this disease. (4) Gas embolism: Gas embolism is one of the causes of death in laparoscopic surgery, and the risk is very high, mainly due to improper placement of Veress needle and intra-abdominal hypertension. The air stagnation can cause venous return and blockage of the right atrium, causing bruises in the head and neck or hearing a "water wheel-like" murmur in the pericardial area, which can be diagnosed. Intraoperative monitoring of end-tidal CO2 concentration contributes to the early diagnosis of air embolism. Once diagnosed, the agitation should be stopped immediately, the patient's head should be placed in the left lateral position, the cardiopulmonary resuscitation should be prepared, the central venous cannula should be intubated, and the right ventricle gas can be aspirated. The gas can be dissolved by excessive ventilation using 100% oxygen. Hyperbaric oxygen chamber treatment And cardiopulmonary bypass is also a better treatment. 2. Complications caused by operation Veress needle and Trocar needle insertion are the most dangerous techniques for laparoscopic operation, and the resulting complications require open surgery. (1) Vascular injury: It usually occurs during Veress needle or Trocar needle insertion and laparoscopic operation, and common abdominal aorta and vena cava damage. The abdominal aorta of a child or a thin patient is very close to the abdominal wall and there is a high possibility of injury. If a large vessel injury is found or suspected, an exploratory laparotomy should be performed immediately. The Veress needle and the Trocar sheath should not be pulled out to locate the repair and prevent greater damage to the blood vessels, lacerations and major bleeding. Superficial or deep upper abdominal wall vascular injury occurs in the lateral abdominal wall Trocar sheath puncture site, often seen blood dripping from the circumference of the Trocar sheath into the abdominal cavity or out of the abdominal wall, small bleeding can be controlled by the Trocar sheath electrocoagulation layer peritoneum, or Put into the Foley balloon catheter to pull and press to stop bleeding. (2) Abdominal organ damage: The most common injuries are the gastrointestinal tract, liver, and pancreas. The incidence of gastrointestinal injury is 1.0% to 2.7%. In the past, there was a history of abdominal surgery. Because of the adhesion of the peritoneal tunica, the possibility of gastrointestinal injury was greater. The water was fasted 8 hours before surgery, and the stomach tube was left to prevent stomach stab wounds. If the Veress needle and the Trocar sheath are found to cause a hollow organ puncture injury, if there is no leakage of the intestinal contents, conservative treatment may be considered. For those who need open surgery for intestinal injury, the Veress needle and the Trocar sheath should not be pulled out. Look for the damaged area. Small perforation or scratching can be considered for simple repair. For extensive intestinal injury, the intestine should be removed. For patients without intestinal preparation, an extra-intestinal ostomy should be performed. (3) intestinal burns: one of the most serious complications of laparoscopic surgery, most intestinal burns are difficult to find during surgery, usually after 3 to 7 days after surgery with abdominal pain, nausea, hypothermia and leukocytosis . Abdominal X-ray film can show intestinal obstruction. During the operation, small burns and burns can be observed closely and conservatively treated; if the treatment effect is not obvious, the symptoms of peritoneal irritation are aggravated, and laparotomy is needed. Because the extent of burns in the intestines is often wider than actually seen, it is not advisable to suture alone, but it is necessary to extensively remove the inactivated intestines. Drainage tubes should be placed around the wounds, and antibiotics should be given for 8-10 days after surgery. (4) : often occurs in the insertion site of the Trocar sheath. The incision should be as much as possible <5mm. Before pulling out the Trocar sheath, the intra-abdominal CO2 gas should be pumped to reduce the intra-abdominal pressure. All Trocar sheaths should be pulled out under direct vision to detect and treat the sacral omentum or intestine in time. After inserting the Trocar sheath at 10 mm, insert the Trocar sheath, insert the little finger into the abdominal cavity, carefully check for the omentum or intestine, and then close the incision with direct suture. (5) Urinary system injury: mainly ureteral injury, the incidence rate is about 0.2%. Patients with a congenital urinary tract abnormality and a history of abdominal surgery are more likely to have Veress needle and Trocar sheath puncture wounds. Ureteral injury is a serious complication of laparoscopic surgery. For small burns or scratches, ureteral stents can be placed. For a wide range of burns, appropriate repair methods should be used according to the length and location of the lesion. 3. General complications after laparoscopic surgery (1) Infection: Generally not common, preoperative prophylactic application of broad-spectrum antibiotics, postoperative hemostasis on the Trocar puncture site, flushing can prevent infection. A common infection is the formation of a small abscess at the suture site of the Trocar puncture site without special treatment. (2) Deep vein thrombosis formation: multiple lower limbs after operation, and getting out of bed as early as possible can prevent this complication. (3) postoperative abdominal or shoulder pain: due to CO2 gas stimulation of the diaphragm, peritoneum. Before the end of the operation, exhaust the CO2 gas in the abdomen as much as possible to reduce the discomfort of the patient. Oral analgesics usually disappear after 24 to 48 hours. (4) postoperative bleeding: some venous hemorrhage is often found after the reduction of abdominal pressure, need to be electrocautery to stop bleeding. Therefore, the abdominal pressure should generally be reduced to 0.67 kPa (5 mmHg), and all surgical sites should be carefully examined. If there is no active bleeding, the surgery is terminated. In addition, because the Trocar sheath can prevent damaged abdominal wall blood vessels, all Trocar sheaths should be removed under direct vision, which is essential for preventing postoperative bleeding caused by abdominal wall vascular injury. If the patient's hemoglobin continues to decrease after surgery, it may indicate active bleeding. There is excessive pain in the Trocar sheath puncture site, and ecchymosis or hematoma is also a sign of bleeding. Close monitoring of the patient's hemoglobin, correction of any potential coagulation disorder, and conservative treatment can often be successful. If the hematoma continues to increase or hemoglobin continues to decline, the blood vessels that ligated the hemorrhage should be explored.