Ebook Northwestern handbook of surgical procedures: Part 2
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Ebook Northwestern handbook of surgical procedures: Part 2
Section 2: EndocrineSection Editor: Richard H. Bell, Jr.Chapter 50Adrenalectomy: LaparoscopicPeter AngelosIndicationslaparoscopic adrenalectomy is ind Ebook Northwestern handbook of surgical procedures: Part 2dicated for the removal of functional adrenal tumors or nonfunctional rumors that have met appropriate size criteria.PreopWhenever operating on an adrenal gland, it is essential that a pheochromocytoma has been adequately ruled in or out. This is best done with a 24-hour urine sample for vanillyl ma Ebook Northwestern handbook of surgical procedures: Part 2ndelic acid (VMA), catecholamines, and meraneph lines. If rhe patient docs have a pheochromocytoma, prcopcrativc alpha-adrenergic blockade for a perioEbook Northwestern handbook of surgical procedures: Part 2
d of 2-4 weeks and rehydration are necessary. If an aldosterone-secreting tumor is the cause for rhe surgery, rhe patient’s potassium level should be Section 2: EndocrineSection Editor: Richard H. Bell, Jr.Chapter 50Adrenalectomy: LaparoscopicPeter AngelosIndicationslaparoscopic adrenalectomy is ind Ebook Northwestern handbook of surgical procedures: Part 2g room is set up with the monitors just off the patient's shoulders. After a general endotracheal anesthetic has been given, the patient is placed in the lateral decubitus position with the side of the tumor up. rhe patient is placed on the operating table in such a way that the kidney rest can be e Ebook Northwestern handbook of surgical procedures: Part 2levated and the table flexed, maximizing the space between the costal margin and the anterior superior iliac spine. The surgeon stands facing the patiEbook Northwestern handbook of surgical procedures: Part 2
ent's abdomen.Step 2. The patient’s entire side extending down the abdomen and the back is prepped and draped in rhe normal sterile fashion, rhe lowerSection 2: EndocrineSection Editor: Richard H. Bell, Jr.Chapter 50Adrenalectomy: LaparoscopicPeter AngelosIndicationslaparoscopic adrenalectomy is ind Ebook Northwestern handbook of surgical procedures: Part 2eadths below rhe costal margin extending from the posterior axillary line to rhe midclavicular line with al least 6 cm between the port sites. A pneumoperitoneum is then created with a Vcrcss needle inserted through a small nick in the skin. For left adrenalectomy, the Veress needle is inserted thro Ebook Northwestern handbook of surgical procedures: Part 2ugh one of the marked port sires near the anterior axillary line. On the right side, to avoid injury to the liver, the pneumoperitoneum is created thrEbook Northwestern handbook of surgical procedures: Part 2
ough a separate stab wound closer to rhe umbilicus.Step 4. After creating the pneumoperitoneum, a 5 or 10 mm port is placed into the peritoneal cavitySection 2: EndocrineSection Editor: Richard H. Bell, Jr.Chapter 50Adrenalectomy: LaparoscopicPeter AngelosIndicationslaparoscopic adrenalectomy is ind Ebook Northwestern handbook of surgical procedures: Part 2in the positions identified. It may be necessary to take down the lateral attachments of the left colon to place the last port on the left side or mobilize a portion of the right lobe of rhe liver on rhe right side.Endocrine—Adrenalectomy: Laparoscopic139Figure 50.1. Laparoscopic adrenalectomy. Pati Ebook Northwestern handbook of surgical procedures: Part 2ent position and port placement.Step 5. For left-sided adrenalectomy, the lateral attachments of the spleen are divided with a harmonic scalpel. ThisEbook Northwestern handbook of surgical procedures: Part 2
allows the spleen to fall medially, taking the tail of the pancreas with it and opening up the retroperitoneal space. On the right side, it is necessaSection 2: EndocrineSection Editor: Richard H. Bell, Jr.Chapter 50Adrenalectomy: LaparoscopicPeter AngelosIndicationslaparoscopic adrenalectomy is ind Ebook Northwestern handbook of surgical procedures: Part 2lpel is used to separate tissue to allow identification of the inferior vena cava.Step 6. On the left side, the kidney is identified and the tissue superior and medial to it is inspected to allow identification of the left adrenal gland. If there is difficulty’ identifying the gland, a laparoscopic Ebook Northwestern handbook of surgical procedures: Part 2ultrasound probe can be used to identify an adrenal mass in the retroperitoneal fat. On the right side, the dissection involves also identifying the kEbook Northwestern handbook of surgical procedures: Part 2
idney and then identifying rhe adrenal gland in the tissue medial and superior to the kidney. No matter which side is being dissected, the harmonic scSection 2: EndocrineSection Editor: Richard H. Bell, Jr.Chapter 50Adrenalectomy: LaparoscopicPeter AngelosIndicationslaparoscopic adrenalectomy is ind Ebook Northwestern handbook of surgical procedures: Part 2he gland.Step 7. If a pheochromocytoma is present, the adrenal vein should be controlled first, by identifying rhe vessel, doubly clipping it, and then dividing it. The right adrenal vein is quire short and can cause significant problems with hemorrhage if not carefully dissected and divided.Step 8. Ebook Northwestern handbook of surgical procedures: Part 2 rhe posterior and superior attachments of rhe adrenal gland are divided with the harmonic scalpel, allowing the gland to be carefully separated fromEbook Northwestern handbook of surgical procedures: Part 2
all of the surrounding tissues.140Northwestern Handbook of Surgical ProceeduresFigure 50.2. Laparoscopic adrenalectomy. Adrenal anatomy.Step 10. The pSection 2: EndocrineSection Editor: Richard H. Bell, Jr.Chapter 50Adrenalectomy: LaparoscopicPeter AngelosIndicationslaparoscopic adrenalectomy is ind Ebook Northwestern handbook of surgical procedures: Part 2uid to allow adequate hemostasis to be confirmed. The ports are then removed and the fascia closed on each with interrupted o Vicryl sutures. The skin is closed with monofilament absorbable subcuticular stitches.PostopIf a pheochromocytoma has been removed, patients are observed overnight in the ICƯ Ebook Northwestern handbook of surgical procedures: Part 2 to allow adequate fluid resuscitation as necessary and close observation of blood pressure. Most patients can be safely discharged 1-2 days after a lEbook Northwestern handbook of surgical procedures: Part 2
aparoscopic adrenalectomy.ComplicationsPatients should be closely followed for any signs of hemorrhage or peritonitis due to injury of any of the orgaSection 2: EndocrineSection Editor: Richard H. Bell, Jr.Chapter 50Adrenalectomy: LaparoscopicPeter AngelosIndicationslaparoscopic adrenalectomy is ind Ebook Northwestern handbook of surgical procedures: Part 2 All should be followed as appropriate to ascertain resolution of symptoms and signs (e.g., hypertension). Pheochromocytoma patients should have annual 24-hour urine sampling for VMA, catecholamines, and metanephrine levels.Chapter 51Pancreatic Endocrine Tumor EnucleationDaphne w. Denham Ebook Northwestern handbook of surgical procedures: Part 2Section 2: EndocrineSection Editor: Richard H. Bell, Jr.Chapter 50Adrenalectomy: LaparoscopicPeter AngelosIndicationslaparoscopic adrenalectomy is indGọi ngay
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