Journal Surgery
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VISCERAL SURGERY VIDEOS
Adrenalectomy with nephrectomy, right hepatectomy and inferior vena cava thrombectomy for adrenocortical carcinoma (with video)
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F. Prunela, S. Bonnetª, S. Gaujoux a,b,*, B. Dousset a,b
a Digestive, Endocrine and Pancreatic Surgery, Cochin Hospital, AP-HP, 75014 Paris, France b Université Paris Descartes, 75005 Paris, France
Available online 7 July 2018
KEYWORDS
Adrenalectomy; Adrenocortical carcinoma; Thrombectomy; Hepatectomy
MOTS CLÉS Surrénalectomie ; Corticosurrénalome ; Thrombectomie ; Hépatectomie
Adrenocortical carcinoma is a rare malignant tumor representing less than 0.1% of all can- cers. A European consensus conference recently defined the surgical standards of care i.e., en bloc surgery, without tumoral effraction, associated with regional lymph node dis- section [1]. This resection on the right side can be complex because of hepatic invasion, which might require right hepatectomy by anterior approach and/or by the presence of a caval tumor thrombus which can rise beyond the suprahepatic veins requiring intraperi- cardial vena cava clamping (Fig. 1) [2]. This video shows a right adrenocortical carcinoma which was removed en bloc with the right kidney, the right liver with an extended lym- phadenectomy, and caval thrombectomy. The patient was placed in supine position and a bilateral subcostal incision with midline cephalad extension was performed (Fig. 2). The procedure began with a full dissection of the right colon with Kocher maneuver allowing to reach the right kidney. The right ureter and genital pedicles were cut and the dissection was performed until the right renal pedicle was ligated. Right anterolateral cavolysis was performed as well as control of the right elements of the hepatic pedicle. Before starting the right hepatectomy, a diaphragmatic section was performed to control the inferior vena cava above superior hepatic veins (intrapericardial approach). After performing a hanging
* Corresponding author. Department of Digestive and Endocrine Surgery, Université Paris Descartes, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
maneuver, hepatic transection was initiated in a conven- tional way, until stapling of the right suprahepatic vein [3]. Then, the lateral retroperitoneal dissection was completed allowing to completely mobilize the kidney and the right liver. This right adrenocortical carcinoma was removed en bloc with the right kidney, the right liver with an extended lymphadenectomy. Once the specimen was removed, the hepatic pedicle and vena cava were clamped to perform an inferior vena cava thrombectomy(Fig. 3). This was done by
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a longitudinal venotomy allowing to remove the entire vena cava thrombus. The inferior vena cava was then sutured longitudinally by running sutures of nonabsorbable sutures. Once the thrombus was removed, the intrapericardial clamp was placed below the suprahepatic veins in order to remo- ving the total vascular exclusion of the liver. This video shows the different steps necessary to perform a right adrenocortical carcinoma resection with caval thrombec- tomy with an en bloc resection of the right kidney plus right liver resection with an extended lymphadenectomy (Fig. 4).
Disclosure of interest
The authors declare that they have no competing interest.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the online version, at http://dx.doi.10.1016/ j.jviscsurg.2018.06.005.
References
[1] Gaujoux S, Mihai R, joint working group of E, et al. European Society of Endocrine Surgeons (ESES) and European Network for
the Study of Adrenal Tumours (ENSAT) recommendations for the surgical management of adrenocortical carcinoma. Br J Surg 2017;104(4):358-76.
[2] Chiche L, Dousset B, Kieffer E, et al. Adrenocortical car- cinoma extending into the inferior vena cava: Presentation
of a 15-patient series and review of the literature. Surgery 2006; 139(1):15-27.
[3] Belghiti J, Guevara OA, Noun R, et al. Liver hanging maneuver: a safe approach to right hepatectomy without liver mobilization. J Am Coll Surg 2001;193(1):109-11.