RU2266062C1 - Surgical access to adrenal glands - Google Patents

Abstract

FIELD: medicine, surgical endocrinology.

SUBSTANCE: one should perform extrapleural access to both right- and left-hand adrenal glands. One should dissect skin in XI intercostals area along the ribs against paravertebral line laterally, the length being 3-3.5 cm. In patients of dolichomorphous and mesomorphous constitutional types one should keep pleural sinus to be intact. In those of brachimorphous constitution one should exfoliate pleural sinus followed by retroperitoneoscopy. The innovation enables to decrease traumatism of surgical access to adrenal glands.

EFFECT: higher efficiency.

1 dwg, 1 tbl

Description

The invention relates to medicine, in particular to surgical endocrinology, and can be used to perform operations on the adrenal glands.

Currently, a large number of accesses to the adrenal glands have been developed and put into practice. Many authors prefer lumbar access, in which the integrity of the peritoneum and pleura is preserved, there is sufficient operational space (Kazaryan A.M., Kuznetsov N.S., Shulutko A.M., Beltsevich D.G. Surgical access to adrenal tumors. Surgery named after N.I. Pirogov, 2003, No. 9, pp. 61-68). Various lumbar approaches are proposed: lateral and posterior. The angle of operation with lateral access is 54-64 °, the access itself is technically simple, vital organs do not adhere to the surgical wound (Shraer T.I., Rozina N.S. Thoracophrenotomy as an access for adrenalectomy. Clinical Medicine, 1978, vol. 56, No. 8, pp. 70-73). However, in our opinion, lateral approaches have several drawbacks, which primarily include a significant depth of the surgical wound, which makes it difficult to perform a wide revision of the retroperitoneal space. In addition, the upper edge of the surgical wound is limited to XI-XII ribs, respectively, decreases the field of surgical action. A significant drawback of the lateral approaches, in our opinion, is the difficulty in isolating the medial edge of the adrenal gland and its central vein, especially in the case of right-sided lesions and in large tumors.

A number of surgeons use posterior lumbar approaches (Zilberman MN, Baev VA Direct retroperitoneoscopy. Orenburg, 1988, 61 pp .; Kalinin AP, Kulikov LK Surgical access to the adrenal glands (lecture). Problems of endocrinology. , 2001, v. 47, No. 1, p. 28-30). These accesses differ in length, location of the incision, the presence or absence of rib resection, dissection or preservation of the integrity of the diaphragm (Sozon-Yaroshevich A.Yu. Anatomical and clinical justification of surgical access to internal organs. L., Medgiz, 1954, p.13- 29, 153-167; Kulikov L.K., Alaberdin S.V., Privalov Yu.A., Sobotovich VF Transcostal lumbolaparotomy for operations on the adrenal gland Surgery, 2001, No. 12, pp. 11-13; Chernyshev VN, Ayupov AM The choice of surgical access to the adrenal glands: Modern aspects of surgical endocrinol ology. Samara, 1994, s.297-299). Lumbar approaches provide a small depth of the surgical wound, the possibility of revision of retroperitoneal tissue. The disadvantages of this access group, in our opinion, are the high morbidity associated with the intersection of a large array of muscles, neurovascular bundles, and resection of the XI-XII ribs. In addition, the angle of operation for these accesses does not exceed 58-65 °, and in some cases is 25-30 °, which leads to a limitation of the surgical field. Another drawback, in our opinion, is the mismatch of the access location of the projection of the adrenal gland, which leads to a decrease in the angle of inclination of the axis of the operational action and, accordingly, worsens the operating conditions of the surgeon. With lumbar accesses, isolation and ligation of the central adrenal vein are difficult.

It should be noted that the authors of the proposed lateral and lumbar accesses do not take into account the peculiarities of the location of the adrenal glands depending on the constitutional type of the patient, and in some cases the access location is unjustifiably, in our opinion, underestimated, thereby leading to difficulties in the implementation of the surgical adrenal gland.

Several retroperitoneoscopic approaches to the adrenal glands have been proposed: lumbocostal, in the X intercostal space (Zilberman MN, Shuleshko SF Direct retroperitoneoscopy as a diagnostic method. “Questions of experimental and clinical urology”, Orenburg, 1973, p. 78-80; Kurbatov D .G. The use of retroperitoneoscopy in surgery of organs of the retroperitoneal space. Diss .... Candidate of Medical Sciences, Kemerovo, 1994, p.41).

With lumbocostal access, proposed by Zilberman M.N. et al. (1973), a soft tissue incision for access to the adrenal gland 3-3.5 cm long is performed parallel to the costal arch in the corner between the XII rib and the outer edge of the muscle that extends the spine. Given the boundaries of the pleural sinus (Kalinin A.P., Maistrenko N.A. et al. Adrenal Surgery. M., Medicine, 2000, p. 11) and the low location of the adrenal glands in individuals with a brachymorphic physique, this access makes it relatively easy to find the adrenal gland and perform manipulations on it. However, in patients with dolichomorphic and mesomorphic body types, this access, in our opinion, is of little use. One of its main drawbacks, in our opinion, is the mismatch of the incision site of the soft tissues of the projection of the adrenal glands, which leads to an increase in the depth of the narrow surgical wound. A low incision in relation to the location of the adrenal gland in patients of the dolichomorphic and mesomorphic constitution leads to difficulties, and in some cases the impossibility of finding the adrenal gland due to the large depth of the wound and the surface of the kidney adjacent to the wound. In addition, in our opinion, with lumbocostal access, manipulation of the central adrenal vein is very difficult due to poor visibility in a deep narrow surgical wound, there is a high probability of injury to the posterior surface of the kidney adjacent to the wound. Similar disadvantages of this access are connected, as it seems to us, with the fact that in these two constitutional types both adrenal glands are located higher than in brachymorphic patients, which leads to an increase in the depth of the wound and the angle of inclination of the axis of the surgical action.

Closest to the proposed is lateral retroperitoneoscopic access to the adrenal glands, proposed by Kurbatov D.G. (Kurbatov D.G. Application of retroperitoneoscopy in surgery of organs of the retroperitoneal space. Diss .... candidate of medical sciences, Kemerovo, 1994, p.41). Access is performed in the position of the patient lying on the opposite side. An incision of the skin and adjacent soft tissues is performed in the X intercostal space along the anterior axillary line. After cutting the superficial fascia, the adjacent muscle layers are bluntly bred. A finger is inserted into the wound, and a retroperitoneoscope blade is inserted through it. After opening the transverse fascia, the peritoneum exfoliates medially, the retroperitoneal tissue exfoliates, while the kidney with the postrenal fascia is moved down. Moving up the front surface of the kidney, the adrenal gland is found.

In our opinion, one of the disadvantages of this access is the considerable depth of the narrow operational wound. In addition, a large array of retroperitoneal fiber in obese patients makes it difficult, and in some cases makes it impossible to visualize the adrenal gland. In our opinion, with this access, the allocation of the medial edge of the gland and its central vein is difficult to do, which can lead to vein injury and intraoperative bleeding. Another disadvantage, in our opinion, is the significant trauma to the perinephral fiber, which is inevitable with this access.

The novelty of the present invention is the optimization of retroperitoneoscopy in individuals of dolichomorphic and mesomorphic body types due to the incision of soft tissues in the projection of the location of the adrenal gland and the least trauma to the pleural sinus in patients with a brachymorphic constitution ..

A significant difference between the proposed access is the implementation of posterior extrapleural access to the right or left adrenal gland in the XI intercostal space along the paravertebral line, leaving the pleural sinus intact in individuals of dolichomorphic and mesomorphic types and exfoliating in individuals of a brachymorphic physique.

When performing retroperitoneoscopy of the adrenal glands, it is necessary to take into account the body type of the patient, since the location of the adrenal glands and the borders of the pleural sinus differ depending on the constitutional type (Kalinin A.P., Maistrenko N.A. et al. Adrenal Surgery. M., Medicine, 2000, p. 11; Romashchenko PN The rationale for access during endovideosurgical interventions on the adrenal glands (clinical anatomical study). Author .... Candidate of Medical Sciences, St. Petersburg, 2000, 24 pp.). According to Shevkunenko V.N. et al. (Ostroverkhov G.E., Bomash Yu.M., Lubotsky D.N. Operative surgery and topographic anatomy, 1995, p. 56-57), one can distinguish brachymorphic, dolichomorphic and transitional between them - mesomorphic - body shape. A brachymorphic (short-wide) physique is characterized by medium or short stature, short and wide neck, a wide chest with a large epigastric angle, a large relative body length, and short lower limbs. The dolichomorphic constitution is characterized by high growth, a long neck, a narrow chest with a small epigastric angle, a small relative body length, and long lower limbs. The transition between these two body types is the mesomorphic constitutional type.

Access is as follows (see drawing).

The position of the patient is lying on the opposite side on the cushion or on the stomach. An incision of the skin 3-3.5 cm long and subcutaneous tissue is performed in the XI intercostal space along the ribs from the paravertebral line to the lateral side. The edges of the wound are parted by the Farabef hooks, the fibers of the adjacent layers of the muscles are stupidly stratified in the direction perpendicular to the skin wound. Subcostal neurovascular bundle moves up. In patients of the dolichomorphic and mesomorphic constitution, the pleural sinus remains intact, in patients of the brachymorphic type of physique, they peel off with a finger upwards without opening. The intraperitoneal fascia is dissected, the hooks are removed, a finger is inserted into the retroperitoneal space, and a retroperitoneoscope is inserted along it. The fixture illuminator is turned on, and the top lighting is off. The subrenal fascia is dissected, the paranephral tissue is bluntly bred and the posterior surface of the upper pole of the kidney is exposed. The kidney is taken under the hook, the adrenal gland is found, which has a significantly higher density compared with the surrounding fiber, well-defined edges, a pinkish-yellow uneven surface. After isolation of the adrenal gland, it is examined, dimensions, structure, and density are evaluated. The next step is to find the central vein, under which the ligature is applied, the vein is ligated, intersected, and the adrenal gland is removed. The adrenal gland is drained, if necessary, drainage is established, the wound is sutured in layers.

The developed access was tested on 15 non-fixed human corpses, including 6 persons of a dolichomorphic physique, 4 corpses of a mesomorphic physique and 5 corpses of a brachymorphic constitution. Each operation performed two operations: right and left, respectively. The parameters of the proposed access are presented in table 1. The table shows that the depth of the surgical wound at the proposed access does not exceed 10 cm. The angle of the surgical action (54-56 °) provides the surgeon with sufficient opportunity to perform manipulations in the surgical wound. The angle of inclination of the axis of the operational action has values approaching 90 ° (78-79 °), which indicates a good correspondence of the soft tissue incision to the location of the adrenal glands and, accordingly, facilitates the work of the surgeon. From the described, we can conclude that the parameters of the proposed access correspond to the parameters necessary for optimal access to the adrenal glands.

Thus, the proposed method has a small depth of the wound (less than 10 cm), which improves the visualization of the adrenal glands and facilitates the manipulation of them. The angle of operation (54-56 °) provides the surgeon with a sufficient operating field. The angle of inclination of the axis of the operational action with the proposed access is close to 90 °, which indicates good accessibility to the location of the adrenal glands in patients with a dolichomorphic and mesomorphic constitution. All these parameters and, in addition, the proximity of access to the spine provide the possibility of fairly free manipulations on the central vein of the adrenal gland. The proposed access can be used for retroperitoneoscopic adrenalectomy for cysts, adenomas, malignant tumors and metastatic adrenal lesions.

Table 1
Parameters of the proposed access to the right and left adrenal glands according to sectional material Options Right adrenal gland Left adrenal gland Depth of the surgical wound, cm 7.75 ± 0.25 9.17 ± 0.33 Operational angle, degrees 54.67 ± 1.03 55.17 ± 1.4 The angle of inclination of the axis of the operational action, degrees 79 ± 0.23 78 ± 0.2

Claims (1)

Surgical access to the adrenal gland, including retroperitoneoscopy, characterized in that extrapleural access to the right or left adrenal gland is performed by making a skin incision in the XI intercostal space along the ribs from the paravertebral line laterally 3-3.5 cm long, leaving the pleural sinus in persons dolichomorphic and mesomorphic body types intact and exfoliating it in patients with a brachymorphic constitution.