RU2797271C1 - Method of retroperitoneal posterior endoscopic adrenalectomy of large tumors - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: invention can be used in retroperitoneal posterior endoscopic adrenalectomy of large tumors. The patient is placed on the stomach with the hips and knees bent. A 1.5 cm long transverse incision is made under the end of the 12th rib, with the help of the index finger a tunnel is made deep into the retroperitoneal space, a 0.5 cm incision is made under the control of the finger under the end of the 11th rib and a lateral trocar with a diameter of 5 mm is installed, so that the end of the trocar rests against the distal phalanx of the finger, the finger is removed. A balloon-type trocar with a diameter of 12 mm is placed in the first incision, sealed with a syringe, pressure is created in the retroperitoneal space while maintaining CO2 of 20–25 mm Hg using an insufflator and an optical camera is introduced into this trocar. Then, in a 1 cm incision between the spinal column and the first trocar, a medial trocar with a diameter of 10 mm is placed at an angle of 45° into which a manipulator is inserted to mobilize the adrenal gland. An electrolytic Covidien Ligasure instrument is placed in the 5 mm lateral trocar, Gerota's fasciae are opened, and the adrenal vein is coagulated. For left-sided retroperitoneoscopic adrenalectomy, using the Covidien ligasure electrocautery instrument, the left adrenal gland is isolated under the diaphragm, lowered medially, the adrenal vein is found, which is coagulated, mobilizing the lower part of the adrenal gland with the tumor, moving away from the kidney.

EFFECT: method allows to reduce intraoperative blood loss, reduce the level of conversion, ensure the prevention of postoperative complications and reduce the rehabilitation period due to the combination of techniques of the claimed invention.

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Description

The invention relates to the field of medicine, namely to surgery, and can be used in operations associated with the need to remove tumors of the adrenal glands by adrenalectomy.

The frequency of tumors of the adrenal glands is insignificant, more often they are discovered by chance during routine examinations for any other pathology. An adrenal tumor can be benign or malignant, and hormonally or non-hormonally active.

в 1992 г. впервые описали лапароскопическое лечение образований надпочечников, ее выполняли ТПА [1. Gagner Μ, Lacroix A,

Laparoscopic adrenalectomy in cushing's syndrome andpheochromocytoma. NEngl.JMed. 1992;327:1033.https://doi.org/ 10.1056/NEJM199210013271417].At present, minimally invasive methods of treatment are gaining popularity, and instead of open surgery, laparoscopic and robotic methods for the treatment of adrenal neoplasms, such as transperitoneal laparoscopic adrenalectomy (TPA), robotic adrenalectomy, and, more recently, single-port access from one incision, have been used. The choice of one or another approach depends on various parameters of the tumor and patient characteristics (such as tumor size, signs of malignancy, the patient's condition and the experience of surgeons). Gagner M, Lacroix A,

in 1992, for the first time, laparoscopic treatment of adrenal masses was described; it was performed by TPA [1. Gagner M, Lacroix A,

Laparoscopic adrenalectomy in cushing's syndrome and pheochromocytoma. NEngl.JMed. 1992;327:1033.https://doi.org/10.1056/NEJM199210013271417].

Kilboz ВВ,

Experience of an endocrine surgeon in laparoscopic transperitoneal adrenalectomy. BMC Surgery. 2019;19(1):134. https://doi.org/10.1186/sl2893-019-0599-0]. В связи с чем, в настоящее время показания к OA очень ограничены, т.к. осложнения OA могут качественно влиять на уровень жизни пациентов, требовать повторных хирургических вмешательств и экономически невыгодны. ТПА считается стандартным методом лечения при гормональноактивных и негормональноактивных опухолях, даже при больших образованиях до 12-15 см [1. Ветшев П.С, Янкин П.Л., Животов В.А., Поддубный Е.И. Выбор метода хирургического лечения при доброкачественных опухолях надпочечников. Хирургия. Журнал им. Н.И. Пирогова. 2018;6:66-76].TPA is preferred over open adrenalectomy (OA) due to greater safety, less blood loss, shorter operation time, less morbidity, better cosmetic effect, and faster patient recovery [1.

Kilboz VV,

Experience of an endocrine surgeon in laparoscopic transperitoneal adrenalectomy. BMC Surgery. 2019;19(1):134. https://doi.org/10.1186/sl2893-019-0599-0]. In this connection, at present, the indications for OA are very limited, tk. complications of OA can qualitatively affect the quality of life of patients, require repeated surgical interventions, and are not economically viable. TPA is considered a standard treatment for hormonally active and non-hormonally active tumors, even for large tumors up to 12-15 cm [1. Vetshev P.S., Yankin P.L., Zhivotov V.A., Poddubny E.I. The choice of the method of surgical treatment for benign tumors of the adrenal glands. Surgery. Journal them. N.I. Pirogov. 2018;6:66-76].

However, this approach requires the mobilization of intra-abdominal organs and structures, which is associated with a high risk of vascular or organ damage [1. Feo CV, Portinari Μ, Maestroni U, Del Rio P, Severi S, Viani L, Pravisani R, Soliani G, Zatelli MC, Ambrosio MR, Tong J, Terrosu G, Bresadola V. Applicability of laparoscopic approach to the resection of large adrenal tumours: a retrospective cohort study on 200 patients. Surg Endosc. 2016;30(8):3532-3540. https://doi.org/10.1007/s00 464-015-46436]. In addition, postoperative complications are possible, such as intestinal paresis, the risk of adhesions and CO2 retention [Hupe M. C, Imkamp F., Merseburger A. S. Minimally invasive approaches to adrenal tumors: an up-to-date summary including patient position and port placement of laparoscopic, retroperitoneoscopic, robot-assisted and single-site adrenalectomy. Current opinioninurology.2017;27(1):5661.https://doi.org/10.1097/MOU.0000000000000339].

To reduce the complications of the widely used transperitoneal approach, retroperitoneal (RP) or retroperitoneoscopic adrenalectomy (RPS AE) was developed in the 1990s, which has several advantages over TPA and is associated with lower operative risk and excellent postoperative results.

Endovideosurgical approaches, in particular retroperitoneoscopic, have undeniable advantages if the indications for their implementation are observed, individual topographic and anatomical features are taken into account, as well as with strict adherence to methodological aspects, which is clearly demonstrated by the absence of complications and improvement in the immediate results of treatment of patients [Romashchenko P.N., Maistrenko N.A., Blyumina S.G. Tauride Medical and Biological Bulletin. 2021. Vol. 24. No. 2. pp. 109-117].

Including: direct access to the adrenal glands, no manipulation of the peritoneal organs, eliminating the risk of abdominal trauma, less blood loss, shorter operation time, less postoperative pain, shorter hospital stay and improved cosmetic effect [Alesina P. F. Retroperitoneal adrenalectomy - learning curve, practical tips and tricks, what limits wider uptake. Gland Surgery. 2019;8(l):36-40. doi:10.21037/gs.2019.03.11].

From the existing level of technology, a method is known for performing posterior retroperitoneoscopic adrenalectomy, which includes laying the patient directly on the abdomen, making an incision, installing endoports, creating a working space using an endoscope tube, dissection, coagulation and cutting of tissues and blood vessels, detecting an adrenal neoplasm, its sequential mobilization , removal of the working instrument and suturing of the skin incision, characterized in that the incision is made up to 30 mm long under the end of the 12th rib with dissection of the surface layer of the dermis and two punctures are performed along the edges of the wound under the endoscope and the working instrument, first the lower part of the adrenal gland is mobilized, then the lateral surfaces, after which the central vein of the adrenal gland is cut off and the posterior surface is mobilized, and during the entire operation the adrenal gland with the neoplasm is fixed by the upper part, which is cut off last, and after removing the working instrument, a larger diameter trocar is installed through which the tumor is removed.

2. The method according to p. 1, characterized in that the punctures are performed with a diameter of 3 and 8 mm.

3 The method according to claim 1, characterized in that after removing the working instrument, a trocar with a diameter of 10 mm is installed.

4. The method according to claim 1, characterized in that in the case when the adrenal gland sinks to the bottom of the working cavity, additional working instruments are installed through separate punctures under the end of the 11th rib and 5-6 centimeters from the spine, so that they are in the same line with each other (RF patent No. 2 614 218, published on March 23, 2017).

The disadvantages of this technical solution include the following. The size of adrenal neoplasms recommended by the authors for removal by this method is up to 45 mm. Thus, the circle of patients who can be helped, but in whom the size of the neoplasm exceeds the indicated ones, is sharply limited.

In addition, as the authors themselves point out, it is necessary to follow the algorithm for extracting the adrenal gland in order to exclude intraoperative complications. First of all, the lower part of the adrenal gland is mobilized, then the lateral surfaces, the central vein of the adrenal gland is cut off, and the posterior surface is mobilized. The entire period of the operation, the adrenal gland with the neoplasm is fixed by the upper part, which is stopped last. When the upper part of the adrenal gland is cut off at earlier stages, the adrenal gland sinks to the bottom of the working cavity and it becomes impossible to perform the operation with one instrument. In this case, additional working instruments are installed through separate punctures under the end of the 11th rib and 5-6 centimeters from the spine, so that they are in line with each other - and this significantly changes and complicates the surgical tactics.

A known method of endosurgical adrenalectomy in pheochromocytoma, including the isolation and clipping of the central vein of the adrenal gland, the isolation and removal of the pathologically altered adrenal gland, characterized in that the central vein of the affected adrenal gland is preliminarily embolized, and the second stage, after complete stabilization of hemodynamics, is performed surgery, in which the central vein of the adrenal gland is clipped and the pathologically altered adrenal gland is removed (RF patent No. 2245105, January 27, 2005).

Its disadvantages are that this technique is limited and is not performed in all medical institutions, in addition, after catheterization of the adrenal vein, the patient is in the surgical department in order to prepare for the second stage - adrenalectomy, which lengthens the bed-day stay in the surgery department and is economically unfavorable for the medical institution. If a hormonally active tumor of the adrenal gland is confirmed before hospitalization, it is necessary to prescribe preoperative preparation with doxosazine on an outpatient basis for 3 weeks to stop a sharp rise in blood pressure during surgery, thereby performing a one-stage operation upon admission to the hospital.

A known method of laparoscopic right-sided adrenalectomy, the essence of which lies in the operating position of the patient on the left side. Due to the lateral position of the patient, the right half of the colon and duodenum is displaced medially, which opens up visual and instrumental access to the hepatorenal pocket, where the right adrenal gland is located retroperitoneally (Illustrated guide to endoscopic surgery / Edited by S.I. Emelyanov. - M. : Medical Information Agency, 2004. - 218 p.).

Its disadvantages are that such methods of performing operations on the adrenal glands have a significant number of limitations, including, in the presence of severe pathology of the spinal column, there is a risk of a fracture of the spine, since the forced position on the left side with a roller placed under it puts a load on the spinal column. column, being in a non-physiological position. There is also a risk of circulatory failure with tense carboxyperitoneum in patients with severe forms of heart failure.

The closest to the claimed technical solution is the Method for performing posterior retroperitoneoscopic adrenalectomy (RF patent No. 2 614 218, publ. 03/23/2017).

The disadvantages of the prototype are eliminated by the proposed technical solution.

The task to be solved by the claimed invention is the development of an alternative method of surgical treatment of adrenal tumors with better postoperative results.

This problem is solved due to the fact that, according to the method, the patient is laid on the stomach with bent hip joints and knees and fixed at an angle of 75-90 °, a 1.5 cm long transverse incision is made under the end of the 12th rib, a tunnel is made using the index finger deep into the retroperitoneal space, and under the control of the finger under the end of the 11th rib, a 0.5 cm incision is made and a lateral trocar with a diameter of 5 mm is installed, so that the end of the trocar rests against the distal phalanx of the finger, the finger is removed, a trocar with a diameter of 12 mm is placed in the first incision balloon type, seal and create pressure in the retroperitoneal space while maintaining C2 20-25 mm Hg. Art. using an insufflator; an optical camera is introduced into this trocar; then, in a 1 cm incision between the spinal column and the first trocar, a medial trocar with a diameter of 10 mm is placed at an angle of 45°, where a manipulator is placed to mobilize the adrenal gland; an electrolytic Covidien ligasure instrument is installed in the 5 mm lateral trocar with the opening of Gerota's fascia and the adrenal vein is coagulated; complete the mobilization of the right adrenal gland by coagulation of additional small vessels; retroperitoneoscopic adrenalectomy is performed using a 10 mm endoscope with a viewing angle of 30 degrees, which is inserted through a 12 mm trocar with an inflatable balloon; extraction of adrenal tissue is performed through a polyethylene container, which is placed in a 12 mm trocar with immersion into the retroperitoneal space, the removed adrenal gland with a tumor is placed in it and removed together with a 12 mm trocar.

The method according to claim 1, characterized in that for left-sided retroperitoneoscopy, the adrenal vein is prepared in the space between the adrenal gland and the diaphragm - medial to the upper pole of the kidney, the left adrenal gland is isolated under the diaphragm using the Covidien ligasure electrocoagulation tool, lowered medially, the adrenal vein is found, which is coagulated , mobilizing the lower part of the adrenal gland with the tumor, moving away from the kidney; otherwise, technically, the operation is performed in the same way as with surgery on the right adrenal gland

The technical result provided by the given set of features is the reduction of intraoperative blood loss, reduction of bed days, low conversion rate, prevention of postoperative complications and reduction of the rehabilitation period.

The essence of the invention is illustrated by drawings, which show:

In FIG. 1 - The position of the patient during the operation;

In FIG. 2 - Installation of trocars for access to the adrenal gland;

Nafig. 3 - Fascia Gerota;

In FIG. 4 - Formation of the adrenal gland;

In FIG. 5 - Isolation of the adrenal vein;

In FIG. 6 - Cosmetic effect after RPS AE.

The technical result provided by the above set of features is achieved through the following original techniques. Patient position: prone position with hips flexed and knees at 75-90° with fixation (Fig. 1) is necessary to create sufficient space between the ribs and the iliac crest. In this case, the lateral wall of the abdomen is located with the vertical line of the table, which ensures the free movement of all instruments.

After making a transverse incision 1.5 cm long under the end of the 12th rib, the retroperitoneal cavity was prepared: using the index finger, a tunnel was made deep into the retroperitoneal space, and under the control of the finger under the end of the 11th rib, a 0.5 cm incision was made and a trocar with a diameter of 5 mm so that the end of the trocar rests against the distal phalanx of the finger. A balloon-type trocar with a diameter of 12 mm was introduced into the area of the 1st incision and sealed with a balloon, located at the end of the trocar with a syringe with air. Pressure was created in the retroperitoneal space while maintaining CO2 20-25 mm Hg. using an inflator. After the introduction of the optical camera, a revision of the zone of the kidney and adrenal gland with a tumor was performed. For further manipulation, a trocar 10 mm in diameter was placed in a 1 cm incision between the spinal column and the first trocar at an angle of 45° for further manipulations on the organ. Retroperitoneoscopy was performed using a 10 mm endoscope with a viewing angle of 30 degrees, which was inserted through a trocar with an inflatable balloon, thereby increasing the viewing angle.

Thus, safe placement of trocars became possible without visual control of the endoscope.

A Covidien Ligasure electrolytic instrument was placed in a 5 mm trocar. Mobilization of the adrenal gland medially and caudally with Covidien Ligasure allowed further mobilization to clearly visualize the right short adrenal vein, which is usually located close to the diaphragm. The adrenal vessels were separated by electrocoagulation and transected.

For left-sided retroperitoneoscopy, given that the left adrenal gland is anatomically located slightly higher than the right one and the central vein of the left adrenal gland, 3 cm long, flows into the renal vein, the adrenal vein was prepared in the space between the adrenal gland and the diaphragm - medial to the upper pole of the kidney. Using an electrocoagulation instrument, the left adrenal gland was isolated under the diaphragm and, descending medially, the adrenal vein was found, which was coagulated, thereby mobilizing the lower part of the adrenal gland with the tumor, moving away from the kidney.

Detailed description of the method and examples of its specific implementation

The criteria for selection for surgery were: patients under 70 years of age, benign functioning tumors of the adrenal glands up to 12 cm in diameter inclusive, patients with stable hemodynamics. Based on the patient's history and physical examination, appropriate hormonal tests were performed, including serum cortisol levels, 24-hour urinary free cortisol, 24-hour urine metanephrines, normetanephrines, plasma aldosterone, and plasma renin-aldosterone ratio. Computed tomography (CT)/magnetic resonance imaging (MRI) was performed to determine the location and diameter of the adrenal mass.

Indications for adrenalectomy were hormonally active adrenal formations of any size, tumors with a diameter of more than 4 cm, suspicious for malignant formations and formations with negative growth dynamics during observation. With a confirmed diagnosis of pheochromocytoma, cardiological examination and the subsequent administration of alpha- and beta-blockers to regulate blood pressure were recommended at least 14 days before surgery. Patients with Conn's disease with a low level of potassium in the blood serum in the preoperative period were treated with potassium and spironolactone preparations.

Informed consent was obtained from all patients, which mentioned the potential risks and benefits of the proposed surgery. All operations were performed by a retroperitoneal retroperitoneal approach by a single surgeon with experience in laparoscopic surgery, with the assistance of a qualified joint team.

Retroperitoneoscopic adrenalectomy was performed under general anesthesia with tracheal intubation and assisted ventilation. Surgery was performed with the patient in the prone position with the hips and knees flexed at an angle of 75-90° (Fig. 1) This placement is necessary to create sufficient space between the ribs and the iliac crest. In this case, the lateral wall of the abdomen is located with the vertical line of the table, which ensures the free movement of all instruments.

A 1.5 cm long transverse incision is made under the end of the 12th rib. Using the index finger, a tunnel is made deep into the retroperitoneal space, and under the control of the finger, a 0.5 cm incision is made under the end of the 11th rib and a lateral trocar with a diameter of 5 mm is installed to the end of the trocar rested against the distal phalanx of the finger. After that, remove the index finger. A balloon-type trocar with a diameter of 12 mm is placed in the first incision, sealed with a syringe, inflating the balloon at the end of the trocar. Create pressure in the retroperitoneal space with the maintenance of CO2 20-25 mm Hg. Art. using an insufflator and introduce an optical camera into this trocar, performing a revision of the zone of the kidney and adrenal gland with a tumor. Then, in a 1 cm incision between the spinal column and the first trocar, a medial trocar with a diameter of 10 mm is installed at an angle of 45°, into which a manipulator is inserted to mobilize the adrenal gland; an electrolytic instrument Covidien Ligasure is installed in the lateral trocar 5 mm, Gerota's fasciae are opened.

Retroperitoneoscopy is performed using a 10 mm endoscope with a 30 degree viewing angle, which is inserted through a 12 mm trocar with an inflatable balloon, thereby increasing the viewing angle (Fig. 2).

After insufflation of the gas and creation of a retroperitoneal space under the diaphragm by displacement of the adipose tissue, the upper pole of the kidney and the adrenal gland are visualized (Fig. 4). The kidney was displaced downward with a laparoscopic manipulator. Using the Covidien Ligasure electrolytic instrument, the adrenal gland is mobilized medially and caudally. The adrenal vessels are separated by electrocoagulation and transected.

With further mobilization, the right short adrenal vein became clearly visible, usually located close to the diaphragm (Fig. 5). The vena cava was clearly visualized after isolation from the fibro-adipose tissue. During this manipulation, the renal vein and artery should not be identified, since the adrenal vein is located above these formations and there is no need to revise this zone.

The adrenal vein was coagulated with a Covidien Ligasure electrolytic instrument without additional clipping. Adrenal mobilization was completed with coagulation of additional small vessels. For right-sided RPS, an AE vein of the adrenal gland is prepared in the space between the adrenal gland and the diaphragm medial to the upper pole of the kidney. All manipulations with the adrenal gland are performed using blunt palpation probes to prevent injury to the adrenal gland, given the delicate capsule and abundant blood supply to the organ.

For left-sided retroperitoneoscopic adrenalectomy, the adrenal vein is prepared in the space between the adrenal gland and the diaphragm - medial to the upper pole of the kidney. Using the Covidien Ligasure electrocoagulation instrument, the left adrenal gland is isolated under the diaphragm and descending medially, the adrenal vein is identified, which is coagulated, thereby mobilizing the lower part of the adrenal gland with the tumor, moving away from the kidney.

The rest is technically performed in the same way as with surgery on the right adrenal gland.

Extraction of adrenal tissue is performed through a polyethylene container placed through a 12 mm trocar into the retroperitoneal space. The removed adrenal gland with the tumor is immersed in a polyethylene container and removed together with a 12 mm trocar.

Drainage in the retroperitoneal space is not installed.

The operation time was determined from the moment of introduction of the optical system and removal of the drug from the retroperitoneal space. Carried out early activation of the patient on the first day after surgery. On the 3rd day, the patient is discharged from the hospital under the supervision of an endocrinologist with an excellent cosmetic effect (Fig. 6). One year after surgery, a follow-up CT scan is performed.

The performance of the proposed method is confirmed by the following clinical examples:

Example 1

Patient K-eva, 47 years old, was admitted to the Department of Endocrine Surgery with a diagnosis of pheochromocytoma of the right adrenal gland. The tumor is hormonally active. During the last 5 years, blood pressure has increased to 250/130 mm Hg. After the examination, according to CT data, a large formation measuring 8.5×10×9.5 cm was found in the region of the right adrenal gland, pushing the upper pole of the right kidney down and medially. After the additional examination and preoperative preparation, the patient was operated on using this technique. RPS AE was performed under general anesthesia with tracheal intubation and assisted ventilation. Surgery was performed with the patient in the prone position, while the hip joints and knees were bent and fixed at an angle of 75-90°.

After a transverse incision 1.5 cm long under the end of the 12th rib, a tunnel is made deep into the retroperitoneal space with the help of the index finger, and under the control of the finger under the end of the 11th rib, a 0.5 cm incision is made and a lateral trocar with a diameter of 5 mm is installed, so that the end of the trocar rests on the distal phalanx of the finger. After that, we remove the index finger from the retroperitoneal tunnel and place a balloon-type trocar with a diameter of 12 mm in the place of the first incision, seal it with a syringe, inflating the balloon at the end of the trocar. We create pressure in the retroperitoneal space while maintaining CO2 20-25 mm Hg. using an insufflator and introduce an optical camera into this trocar, performing a revision of the zone of the kidney and adrenal gland with a tumor. Then, a medial trocar 10 mm in diameter was placed in a 1 cm incision between the spinal column and the first trocar at an angle of 45°, where a manipulator was placed to mobilize the adrenal gland.

An electrolytic Covidien ligasure instrument was placed in the 5 mm lateral trocar with opening of Gerota's fascia. Retroperitoneoscopy was performed using a 10 mm endoscope with a viewing angle of 30 degrees, which was inserted through a 12 mm trocar with an inflatable balloon. After gas insufflation and creation of a retroperitoneal space under the diaphragm by displacement of adipose tissue, the upper pole of the kidney and the adrenal gland were visualized. The kidney was displaced downward with a laparoscopic manipulator. Using the Covidien Ligasure electrolytic instrument, the adrenal gland was mobilized medially and caudally. The adrenal vessels were separated by electrocoagulation and crossed. With further mobilization, the right short adrenal vein became clearly visible, located close to the diaphragm. The vena cava was clearly visualized after isolation from the fibro-adipose tissue. The adrenal vein was coagulated with a Covidien Ligasure electrolytic instrument without additional clipping. Mobilization of the adrenal gland was completed with coagulation of additional small vessels. RPS AE adrenal vein was prepared in the space between the adrenal gland and the diaphragm medial to the upper pole of the kidney. All manipulations with the adrenal gland were performed using blunt palpation probes to prevent injury to the adrenal gland, given the delicate capsule and abundant blood supply to the organ. The adrenal tissue was removed through a polyethylene container placed through a 12 mm trocar into the retroperitoneal space. The removed adrenal gland with the tumor was immersed in a polyethylene container and removed together with a 12 mm trocar.

The patient had an extremely low level of postoperative pain, the patient refused painkillers. On the first day after the operation, the patient was early activated. On the third day, the patient was safely discharged from the hospital under the supervision of an endocrinologist with an excellent cosmetic effect. A year after surgery, a follow-up CT scan was performed. Which showed no recurrence.

Example 2

Patient H-s, 37 years old, was admitted to the Department of Endocrine Surgery with a diagnosis of non-hormonally active tumor of the left adrenal gland. An additional examination was performed: CT with contrast. The size of the tumor is 8.5×7×6.5 cm. According to CT data, no malignant neoplasm was detected. The next day, he was taken to the operating room, where, according to the claimed method, the formation of the left adrenal gland was removed. For left-sided retroperitoneoscopic adrenalectomy, the adrenal vein was prepared in the space between the adrenal gland and the diaphragm - medial to the upper pole of the kidney. Using the Covidien Ligasure electrocoagulation instrument, the left adrenal gland was isolated under the diaphragm and descending medially, the adrenal vein was identified, which was coagulated, thereby mobilizing the lower part of the adrenal gland with the tumor, moving away from the kidney.

The rest of the operation was technically performed in the same way as in surgery on the right adrenal gland.

Drainage into the retroperitoneal space was not established. According to histology: myelolipoma of the adrenal gland. After the operation, the patient noted a low level of postoperative pain, painkillers were not prescribed. The patient was discharged from the hospital on the 2nd day under the supervision of an endocrinologist with an excellent cosmetic effect. A year after surgery, a follow-up CT scan was performed. Which showed no recurrence.

According to the claimed method, 44 patients were operated on for an adrenal tumor in the Department of Endocrine Surgery from August 2017 to December 2021. Patients were evaluated according to demographic, clinical, diagnostic criteria, physical examination, laboratory parameters. All patients also underwent computed tomography and magnetic resonance imaging. The outcome of treatment was assessed by the duration of the operation, blood loss, conversion rate, duration of hospitalization and complications.

The group included 24 women and 20 men, mean age 47.0±8.9 years. The average body mass index was 23.5±2.2 kg/m ² . A tumor of the right adrenal gland was found in 18 cases, of the left in 26 cases. benign functioning tumors of the adrenal glands up to 10 cm in diameter inclusive. The average size of the adrenal formation was 10.6=1=0.85 cm. The average operation time was 60.1±21.16 min, the average drop in hemoglobin was 0.47±0.26 g/l. Conversion was required in 1 patient. The average bed-day was 4.0±0.91. The mean recovery time after surgery was 12.18±1.7 days.

The final histopathological findings were dominated by adenoma, which was found in 25 cases, pheochromocytoma in 10 cases, adrenal lipoma in 4, benign cystic tumor in 2, adrenocortical carcinoma in 1 and myelolipoma in 1 case.

The claimed method is safe and effective due to less blood loss, shorter hospitalization, low conversion rate, fewer complications and reduced hospitalization and recovery time.

The benefits also include reduced recovery time, reduced surgical trauma, complication rates, length of stay in the hospital, reduced treatment costs, improved general well-being after surgery, and improved quality of life for patients.

Thus, an effective method for the treatment of patients with a medium-sized adrenal tumor, especially up to 10 cm, is proposed for practical use. The technique is technically safe and is associated with less blood loss, shorter hospital stay, low conversion rate, fewer complications, and early recovery.

Laparoscopic experience and surgical skills are important factors in achieving consistently good results.

Claims (2)

1. A method for retroperitoneoscopic adrenalectomy for large tumors, which includes laying the patient in the prone position, making an incision, installing endoports, creating a working space using an endoscope tube, dissection, coagulation and cutting of tissues and blood vessels, characterized in that the patient is laid on the stomach with bent hips and knees and fixed at an angle of 75-90 °, a 1.5 cm long transverse incision is made under the end of the 12th rib, with the help of the index finger a tunnel is made deep into the retroperitoneal space; under the control of the finger under the end of the 11th rib, a 0.5 cm incision is made and a lateral trocar with a diameter of 5 mm is installed, so that the end of the trocar rests against the distal phalanx of the finger, the finger is removed; a balloon-type trocar with a diameter of 12 mm is placed in the first incision, sealed with a syringe, pressure is created in the retroperitoneal space while maintaining CO2 of 20-25 mm Hg. using an insufflator and introduce an optical camera into this trocar; then, in a 1 cm incision between the spinal column and the first trocar, a medial trocar with a diameter of 10 mm is installed at an angle of 45°, into which a manipulator is inserted to mobilize the adrenal gland; an electrolytic Covidien Ligasure instrument is placed in the 5 mm lateral trocar, Gerota's fasciae are opened, and the adrenal vein is coagulated; retroperitoneoscopic adrenalectomy is performed using a 10 mm endoscope with a viewing angle of 30 degrees, which is inserted through a 12 mm trocar; the removed adrenal gland with the tumor is immersed in a polyethylene container, placed through a 12 mm trocar into the retroperitoneal space, and removed together with the trocar. 2. The method according to claim 1, characterized in that for left-sided retroperitoneoscopic adrenalectomy using the Covidien ligasure electrocoagulation instrument, the left adrenal gland is isolated under the diaphragm, lowered medially, the adrenal vein is found, which is coagulated, mobilizing the lower part of the adrenal gland with the tumor, moving away from the kidney.

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