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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Laparoscopic adrenalectomy

, M.D., , M.D., and , M.D.

Department of Surgery, Division of Laparoscopy, Mount Sinai Medical Centre, New York, U.S.A.

Laparoscopic adrenalectomy was introduced in 1992 (1) and has rapidly become the preferred approach for removal of most adrenal neoplasms. The technique has evolved to include a lateral transperitoneal approach (2) and a retroperitoneal approach (3). The advantages of laparoscopic adrenalectomy over open adrenalectomy include decreased blood loss, less morbidity, decreased length of stay, a more rapid return to regular activity, and greater patient satisfaction (412).

Indications

The indications are similar to open adrenalectomy and include all hormonally active tumors (aldosteronoma, pheochromocytoma, cortisol producing adenoma, virilizing adenoma), bilateral adrenal hyperplasia secondary to Cushing's disease or ectopic ACTH production, symptomatic angiomyolipomas and cysts, and incidentalomas. Historically, pheochromocytoma was an indication for an open anterior approach to allow the surgeon to explore both adrenals and search for extra-adrenal tumors. However, modern imaging techniques (CT, MRI, MIBG) allow for more precise localization thereby facilitating the unilateral laparoscopic approach. Nonfunctioning adrenal masses (incidentalomas) can also be approached laparoscopically unless there is preoperative evidence of malignant invasion into contiguous structures. All surgeons would recommend laparoscopic adrenalectomy for incidentalomas greater than 6 cm in size because there is a 15% risk of malignancy (13). This risk diminishes considerably for tumors less than 6 cm. However, there have been several reports of adrenocortical carcinoma even in tumors less than 3.2 cm (14, 15). Therefore, we feel that any incidentaloma greater than 3 cm should be excised in otherwise young and fit individuals.

Contraindications

Malignancy is the only absolute contraindication to laparoscopic adrenalectomy. This includes adrenocortical carcinoma and pheochromocytoma with nodal or metastatic involvement. The exception to this rule is the resection of metastases to the adrenal when the primary is controlled. Other relative contraindications include coagulopathy, prior laparotomy and size greater than 15 cm.

Operative technique

Laparoscopic adrenalectomy can be performed via a transperitoneal or a retroperitoneal approach. An anterior transperitoneal approach was initially used but quickly fell out of favor due to difficult exposure. The most commonly used approach is the lateral transperitoneal approach. This position allows gravity to aid in retraction and therefore improves exposure.

Laparoscopic right adrenalectomy is performed with the patient in a left lateral decubitus position. The liver will often have to be mobilized to obtain the best exposure of the junction between the adrenal gland and the inferior vena cava. This is accomplished by incising the triangular ligaments allowing for medial retraction of the liver. For small masses, gaining control of the adrenal vein early facilitates dissection of the rest of the gland. For larger masses, we prefer to dissect laterally and superiorly first and then move down along the vena cava to reach the adrenal vein.

Laparoscopic left adrenalectomy is performed with the patient in a right lateral decubitus position. Mobilization of the splenic flexure is usually necessary to open the retroperitoneal space. Dissection then begins lateral to the spleen at the splenorenal ligament. This is continued up to the diaphragm very close to the greater curvature of the stomach and the short gastric vessels. Once the spleen is fully mobilized, it will fall medially exposing the lateral edge and anterior portion of the adrenal gland with the perinephric fat. As is the case on the right side, if the mass is small (less than 5 cm), it is preferable to dissect and secure the adrenal vein first. However, if one is dealing with a large tumor it is easier to start by dissecting along the lateral and superior margins of the adrenal gland. This will allow better mobilization and make it easier to clip the adrenal vein later in the dissection.

Bilateral laparoscopic adrenalectomy is sometimes needed such as for patients with Cushing's syndrome, bilateral pheochromocytoma or rarely, pigmented micronodular hyperplasia. The left side is usually performed first, as it is easier. The patient is rotated after the left adrenalectomy is completed and all trochar sites are closed. This involves a turnover time but we still prefer this to the anterior approach.

The posterior approach has recently been advocated by several authors, especially for small (< 6 cm) lesions (1621). The patient is usually placed in the prone position, which enables bilateral adrenalectomy without repositioning the patient. A retroperitoneal space is created by using a balloon dissector, thereby creating an operating field posterior to the kidney and the adrenal gland. The anatomy is more difficult to delineate and due to the restricted working space, only small tumors can be approached in this manner.

Results

Since it inception in 1992 over 1000 cases of laparoscopic adrenalectomy have been reported in the literature. Unfortunately, there have been no prospective randomized studies evaluating this new technique. There is, however, considerable evidence as to the safety and efficacy of laparoscopic adrenalectomy. Table I shows a summary of published series that consisted of greater than twenty laparoscopic adrenalectomies (48, 11, 12, 15, 17, 2038). These series were reported from 1995 to 1999 and represent 27 authors and 1052 patients. A total of 1082 adrenalectomies were performed which included 30 bilateral resections. The age ranged from 17 to 84 and the male to female ratio was approximately 1 to 1. The size of the lesions varied from 0.5 cm up to 14 cm. The lateral transperitoneal approach (88% of patients) was more common than the posterior retroperitoneal approach. The conversion rate ranged from 0% to 18%. Most lesions (98%) were totally resected but a few recent reports of subtotal adrenalectomy (22 cases) suggest this as yet another option (37). The most common indication was aldosteronoma (42.7%), then Cushing's syndrome (18.6%), incidentaloma (16.9%), and pheochromocytoma (14.7%). There were several other less common indications such as angiomyolipoma, small carcinomas or metastases, virilizing adenomas, and macronodular hyperplasia.

Table I. Series of laparoscopic adrenalectomies.

Table I

Series of laparoscopic adrenalectomies.

Although there have not been any prospective randomized trials comparing the laparoscopic and the open approach, there have been several retrospective studies (46, 812, 3941). The results of these are summarized in table II. Operating time was shorter in the open groups with an average of 149 minutes compared to 195 minutes for the laparoscopic groups. However, there was great variability ranging from an average of 116 minutes to 289 minutes for the laparoscopic approach. Some of this variability can be explained by a learning curve. For example, Winfield had an average operating time of 219 minutes for the first 21 cases, but the last 10 averaged only 160 minutes (6). Rutherford, who has performed the greatest number of laparoscopic resections for aldosteronomas, averaged 152 minutes for the first 20 cases but this dropped to only 109 minutes for the last 40 cases (28). Estimated blood loss (EBL) appears to be less in the laparoscopic groups with an average of 153cc compared to 355cc for the open groups. Analgesic requirements were also considerably less (46, 10, 12, 42). One of the most dramatic findings is the length of hospital stay (LOS). In the open groups this varied from 4.5 days to 9 days, with an average of 6.55 days across all groups. The laparoscopic groups ranged from 1.7 to 3.4 days with an average of 2.57 days. Length of time to full recovery was also noted to be less by several authors (46, 9, 11).

Table II. Laparoscopic versus open adrenalectomy.

Table II

Laparoscopic versus open adrenalectomy.

Complications were less for the laparoscopic groups with an average rate of 7% versus 24%. The most common complication in the laparoscopic groups was postoperative hematoma or need for transfusion with an approximate rate of 3%. Wound complications, pulmonary complications and DVT were all less than 1%. In the open group respiratory complications such as pneumonias or atelectasis were most frequent with a rate of about 6%. Wound infections were reported in 3% and hematomas and transfusion requirements in 3%. There was also a splenectomy and splenic injury rate of 1.5%. Interestingly, Thompson et al. also noted a dramatic late complication rate of 54% for open posterior adrenalectomy (4). These complications consisted of chronic pain in 14%, flank numbness in 10% and muscle laxity in 30%. Therefore it appears justified to state that the morbidity of laparoscopic adrenalectomy is definitely less than that for the open procedure.

The retroperitoneoscopic approach to the adrenal gland was first described by Mercan et al. in 1995 (3). Since that time many surgeons have learned the technique and published their results. More recently, several surgeons have performed retrospective comparisons of the transperitoneal versus the retroperitoneal approaches (1619, 21, 43). These are summarized in table III. There was no significant difference in operating time, blood loss or length of stay. Surgeons who perform both approaches feel that although the outcomes are similar, each has a specific advantage (17). The retroperitoneal approach can avoid intraperitoneal adhesions from previous operations and can save time in bilateral adrenalectomies as the patient does not need to be repositioned. However, the retroperitoneal approach is more difficult to learn because of the lack of familiarity with the anatomy, and the working space is smaller so the technique can only be applied to small tumors.

Table III. Transperitoneal versus retroperitoneal approach.

Table III

Transperitoneal versus retroperitoneal approach.

Laparoscopic adrenalectomy appears to have established itself as the standard of care for most adrenal neoplasms. The open anterior approach still has a place for very large tumors and obvious malignancy, but the open posterior approach has essentially been supplanted. The choice of transperitoneal versus retroperitoneal is at present determined primarily by surgeon preference except in larger tumors where the transperitoneal approach is clearly superior.

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Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6872

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