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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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Surgical management of adrenal neoplasms: laparoscopic versus open adrenalectomy

, M.D. and , M.D.

Department of Surgery, Rush-Presbytherian St. Luke's Medical Center, Rush University, Chicago, IL, U.S.A.

Introduction

Before the era of laparoscopic procedures, conventional open adrenalectomy was the only surgical approach to adrenal neoplasms. Since the introduction of laparoscopic adrenalectomy by Gagner et al. in 1992, the majority of benign adrenal lesions have been removed by various laparoscopic techniques. The decision to utilize open versus laparoscopic approach should be based on body habitus of the patient, the specific type and characteristics of the tumor and the experience of the surgeon. This chapter will discuss the merits of laparoscopic versus open adrenalectomy and the indications for laparoscopic adrenalectomy.

Conventional open methods for adrenalectomy

The choice of conventional open methods for adrenalectomy depends on the size, location, and etiology of the adrenal mass, and the patient's body habitus and associated medical conditions.

The conventional open approaches are:

1.

The flank or posterior,

2.

The anterior or transabdominal,

3.

The transthoracic or thoracoabdominal.

The flank or posterior approach

The incision is made through the bed of the twelfth rib for the flank or posterior approach (1). By staying retroperitoneally, this procedure avoids transgressing the thoracic and peritoneal cavities. This minimizes bowel injury, paralytic ileus, and postoperative pulmonary problems. Since exposure with this approach is limited, it should only be used to remove tumors up to 5 cm in size. Intra-abdominal exploration for other pathology or metastases is impossible, and two separate incisions are required for bilateral adrenalectomy (2, 3).

The anterior or transabdominal approach

The anterior or transabdominal approach is through a midline or upper abdominal transverse (subcostal) incision The advantages of this approach include access to the entire peritoneal cavity and the ability to treat bilateral adrenal disease, extra-adrenal disease or other intra-abdominal pathology. This approach is recommended for large malignant tumors, especially if en bloc resection of contiguous organs is required.

The disadvantage of the anterior approach is that it has all the morbidity of a major laparotomy, especially pain and prolonged ileus (2, 3).

The transthoracic or thoracoabdominal approach

The thoracoabdominal approach is made through a midline incision that extends into the chest through the tenth or eleventh intercostal space. The transthoracic approach uses an incision through the tenth rib on the right or eleventh rib on the left. Both of these approaches provide wide direct exposure and are well suited for tumors larger than 12 cm. They are also useful if en bloc resection is required. Nevertheless, the transthoracic and thoracoabdominal approaches allow for only limited intraperitoneal exploration and only one adrenal gland can be removed, unless the patient is repositioned for a second incision. Both approaches carry the morbidity of a thoracotomy and if the thoracoabdominal approach is taken also a laparotomy (3, 4).

Laparoscopic adrenalectomy

With the advent of laparoscopic instruments and minimally invasive techniques, laparoscopic adrenalectomy became possible. Gagner et al. in 1992 published their method of laparoscopic adrenalectomy. It was quickly adopted by many surgeons and has proven useful for extirpating most benign adrenal lesions.

Laparoscopic approaches in current use are:

1.

lateral transperitoneal (flank),

2.

anterior,

3.

posterior retroperitoneal.

The lateral transperitoneal or flank laparoscopic approach

As described by Gagner et al. (5) (fig. 1), the patient is positioned in a lateral decubitus position with the side of the diseased adrenal gland up. Four trocars are inserted in the flank area, one under the subcostal area at the anterior axillary line and three under the twelfth rib along a line lateral to the first one. The benefits of this approach are essentially the same as other laparoscopic procedures, i.e., less postoperative pain and decreased length of hospital stay. Moreover, this method allows one to inspect much of the abdominal cavity and provides wider exposure for removing relatively larger glands than can be removed with the retroperitoneal approach.

Figure 1. The trocar sites used to perform a right lateral transabdominal laparoscopic adrenalectomy are depicted by the stars.

Figure 1

The trocar sites used to perform a right lateral transabdominal laparoscopic adrenalectomy are depicted by the stars. For a left lateral transdominal laparoscopic adrenalectomy often only 3 subcostal trocar sites are needed.

The drawbacks of this approach are the possibility of bowel or solid organ injury and the morbidity associated with laparoscopic procedures in general such as trocar injuries, longer operative times when compared with open procedures and hemodynamic changes secondary to carbon dioxide insufflation.

The anterior laparoscopic approach

The patient is placed in a semilateral position with the side of the diseased gland up (62), four to five trocars are inserted, one above the navel and two subcostally, one at the anterior axillary line and another at the midclavicular line. The advantages and disadvantages of the anterior approach are similar to the lateral transperitoneal or flank approach. In addition, more dissection and retraction is required which may lead to more bleeding and other injuries. In general the anterior laparoscopic approach has poorer exposure and is technically harder when compared with the other two laparoscopic techniques.

The posterior or retroperitoneal laparoscopic approach

The patient is placed in a semi-jackknife prone position (7) (fig. 3). A balloon trocar is inserted 2.5 cm lateral to the twelfth rib into the retroperitoneum to create a working space. Three more trocars are introduced into the created retroperitoneal space under direct vision: one between the ninth and tenth ribs, a second one 1 cm lateral to the eleventh rib and the third one just below the twelfth rib. The kidney is retracted downward with an atraumatic retractor placed through the port under the twelfth rib. The adrenal gland is mobilized using electrocautery the harmonic scalpel or endoclips as necessary. The superior pole and anterior aspects are first dissected out for both left and right adrenalectomy. The inferior phrenic arterial branches are divided. Care should be taken during right adrenalectomy because the right adrenal vein empties directly into the inferior vena cava. The gland should be free after the main adrenal vein is ligated. The specimen is put into a plastic bag and removed from one of the port sites. Besides decreasing pain and length of hospitalization, the retroperitoneal approach allows one to perform a bilateral adrenalectomy without repositioning the patient. It also avoids adhesions from previous operations and other abdominal conditions that might interfere with the operation. Since the peritoneal cavity is not violated the bowel and other organs are not disturbed. However, the retroperitoneal approach precludes intra-abdominal exploration. Due to its limited working space, large tumors cannot be removed (up to 5 cm).

Figure 3. For the posterior or retroperitoneal laparoscopic approach the patient is positioned in a semi jackknife prone position.

Figure 3

For the posterior or retroperitoneal laparoscopic approach the patient is positioned in a semi jackknife prone position. For laparoscopic right adrenalectomy the 4 trocar sites required to perform the procedure are depicted by the stars. Corresponding (more...)

Currently, we recommend the lateral transperitoneal approach for the following reasons:

a.

The anatomy is more familiar and intraperitoneal landmarks can be used to orient the surgeon.

b.

It allows inspection of much of the peritoneal cavity.

c.

It provides a wider working space and better exposure for removal of larger glands.

d.

It requires less retraction and dissection than the anterior approach.

Laparoscopic versus open adrenalectomy

Figure 4 outlines our algorithm for the surgical management of adrenal neoplasms (8). If an adrenal mass appears malignant on imaging modalities or is greater than 6 cm, the appropriate approach is a conventional open technique. Because of the possibility of port site seeding and the chance of incomplete resection, laparoscopic adrenalectomy is inappropriate for a proven malignant lesion or an adrenal mass that is very likely to be malignant from its imaging characteristics. In general we do not recommend laparoscopic adrenalectomy for adrenal masses greater than 6 cm in size because of the greater possibility of adrenocortical carcinoma in lesions larger than this (9).

Laparoscopic adrenalectomy has become the operation of choice for most benign functional and non-functional adrenal masses less than 6 cm in diameter. Even though there are no prospective randomized studies comparing open versus laparoscopic adrenalectomy, the advantages of the laparoscopic approach (better cosmesis; reduced operative blood loss; less postoperative pain; decreased length of hospital stay; and earlier return to work and normal activities) are clear and have been confirmed in reports from medical centers throughout the world including our own when retrospectively compared with open adrenalectomy (10, 11, 12, 13, 14). Table I summarizes the indications and advantages of laparoscopic versus open adrenalectomy (3).

Table I. Laparoscopic versus open adrenalectomy.

Table I

Laparoscopic versus open adrenalectomy.

In conclusion, the availability of laparoscopic adrenalectomy should not lower the threshold for removing an incidentally identified adrenal mass. Laparoscopy has not changed the indications for adrenalectomy. Surgeons who perform adrenalectomy should be experienced with both open and laparoscopic approaches in order to provide the most appropriate procedure to deal with the particular problems of their individual patients.

Figure 2. The 5 trocar sites used to perform a laparoscopic right adrenalectomy using the anterior approach are depicted by the stars.

Figure 2

The 5 trocar sites used to perform a laparoscopic right adrenalectomy using the anterior approach are depicted by the stars. The lowest midline star is located above the umbilicus. To do a laparoscopic left adrenalectomy with the anteriorapproach the (more...)

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Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6997

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