tailieunhanh - Laparoscopic urologic surgery in malignancies - part 2

Đối với adrenalectomy phải, các khía cạnh bên của tĩnh mạch chủ dưới là một cách cẩn thận theo sau trên nguồn gốc của tĩnh mạch thận cho đến khi các tĩnh mạch thượng thận phải được xác định. Nó thường gặp phải superomedial tuyến riêng của mình. Các tĩnh mạch là chia cắt sạch, cắt và chia. | 14 . Bariol . Tolley For right adrenalectomy the lateral aspect of the inferior vena cava is carefully followed above the origin of the renal vein until the right adrenal vein is identified. It is normally encountered superomedial to the gland itself. The vein is dissected clean clipped and divided. On the left side dissection along the renal vein will identify the adrenal vein arising from its superior aspect. The vein is clipped and divided. Other small branches between the renal hilar vessels and adrenal are commonly encountered and should be dealt with in the same way. Adrenal Mobilisation Following the adrenal vein facilitates identification of the gland particularly on the left side. Dissection is completed medially with ligation and division of aortic branches using laparoscopic clips. The remainder of the gland is mobilization with blunt and sharp dissection although caution should be exercised along the glands superior aspect where inferior phrenic branches are encountered. We have found the endoGIA or the harmonic scalpel to improve haemostatic control during dissection of the gland s medial and superior borders. Oncological surgical principles must be maintained during dissection never handling the tumour or adrenal directly and removing tumour and all surrounding fat en bloc. If oncological safety appears to be compromised because of poor vision or inadequate working space open conversion must be undertaken. Specimen Retrieval The adrenal is grasped with heavy laparoscopic forceps Babcock forceps are ideal . The specimen is held away as the adrenal bed is inspected for bleeding. This inspection should always be performed at low intraabdominal pressure to ensure that venous bleeding is not masked. The pneumoperitoneum is re-established and a small laparoscopic catchment bag is inserted through the 12-mm secondary port and the specimen carefully placed within it and removed intact. Wound Closure A drain should be placed if there is concern about .