Laparoscopic Adrenalectomy Abdominal Approach

Abstract

Since its first description by Gagner et al., in 1992, laparoscopic adrenalectomy has become the gold standard for the surgical treatment of most adrenal conditions [1]. It has generally replaced open adrenalectomy for small- and medium-sized adrenal lesions [2]. The advantages of LA include shorter hospital stays, less postoperative pain, and better cosmetic results [3].

Introduction

Since its first description by Gagner et al., in 1992, laparoscopic adrenalectomy has become the gold standard for the surgical treatment of most adrenal conditions [1]. It has generally replaced open adrenalectomy for small- and medium-sized adrenal lesions [2]. The advantages of LA include shorter hospital stays, less postoperative pain, and better cosmetic results [3].

The lateral transabdominal approach to the adrenals is currently one of the most widely used technique. It allows an optimal comprehensive view of the adrenal region and surrounding structures and provides adequate working space [4]. The magnification of the endoscope is particularly helpful in the course of dissection in this area. A detailed knowledge of retroperitoneal anatomy with gentle tissue manipulation and precise hemostatic technique are essential requirements for a successful laparoscopic adrenalectomy.

Indications

More than 75% of LA’s are performed for endocrine causes of hypertension such as aldosteronoma, Cushing’s syndrome and disease, and pheochromocytoma. Other indications adrenal cyst, metastases, myelipoma, primary adrenocortical neoplasm, androgen-secreting tumors, adrenal hemorrhage, ganglioneuroma, and adrenal tuberculosis [5] (Table 1).

Table 1 Indications and contraindications for laparoscopic adrenalectomy [6]

Adrenalectomy is generally indicated in the following:

• Biochemically functioning tumors.

• Suspected primary adrenal malignancies.

Careful consideration of the imaging characteristics of the lesion (CT/MRI/PET-CT) should be done to assist in decision-making.

Contraindications

Absolute contraindication to LA are patients who are unable to tolerate laparoscopy.

Relative contraindications to laparoscopy include presence of locally invasive tumors that require contiguous resection of other structures, persistent coagulopathy, and inability to perform the procedure safely with minimally invasive techniques.

The size limit to consider LA has been increased progressively from 6 cm, to 8 cm, and to 10–12 cm, depending on the experience of the surgical team [7]. Large adrenal tumors have a higher malignant rate. Sturgeon et al. discovered more malignant incident rate of large adrenal tumor (<4 cm = 5%, > or = 4 cm = 10%, and > or = 8 cm = 47%) [8]. Intraoperative findings, rather than strict reliance on tumor size, should determine whether a patient undergoes laparoscopic versus open adrenalectomy for adrenal cortical tumors [9].

Preop Preparation [6]

• 1. Blood pressure control and correction of electrolyte abnormalities are done preoperatively in patients with functional adrenal mass and hypertension.

• 2. All patients with hypercortisolism should receive intravenous stress-dose corticosteroids and are given immediately before and after adrenalectomy.

• 3. For patients with pheochromocytoma, alpha adrenergic receptor blockade is started 7–10 days prior to surgery. The goal is to achieve control of hypertension and achieve mild orthostasis. Beta adrenergic blockade should be initiated if tachycardia persists, or the tumor is epinephrine secreting.

• 4. Close discussion with the anesthetist team in the preparatory phase is important, particularly in the hemodynamic management of patients with pheochromocytoma.

• 5. Preoperative antibiotic prophylaxis is administered prior to the beginning of the procedure.

• 6. Anti-thrombotic stockings are placed prior to induction of anesthesia and a sequential compression device is utilized.

• 7. Foley catheters are placed in patients with larger tumors or more difficult cases.

• 8. Cross-matched blood should be prepared for vascular tumors or tumors with invasion.

Operating Theater Setup

Instrumentation [10]

• Veress needle.

• 10 mm 30 and 0 laparoscopes.

• 5 mm 30 and 0 laparoscopes.

• One 12 mm and three (left) or four (right) 5 mm non-bladed trocar.

• 5 mm Suction Aspirator (Stryker, Kalamazoo, MI).

• Ultrasonic curved shears—Harmonic scalpel (Ethicon Endosurgery, Cincinnati, OH).

• Laparoscopic scissors.

• 5-mm right angle forceps.

• Graspers-locking and non-locking [2].

• Bipolar forceps (Aesculap or Wolf).

• 5 mm polymer locking clip and applier (Hem-O-Lok-Weck, NC).

• 10 mm specimen retrieval bag (Ethicon or US Surgical).

• PEER retractor (Jarit, Hawthorne, NY).

• Diamond-Flex triangular retractor (Snowden-Pencer, Tucker, GA).

• Optional: 5 mm Ligasure laparoscopic forceps (Valleylab, Boulder, CO).

• Optional: Carter Thomasson Inlet Closure device (Inlet Medical, Eden Prairie, MN).

Patient Position [10]

Patient is placed in a lateral decubitus position with the affected side elevated around 60°. A bean bag is placed to help support the patient in the required position. Axillary pads are placed under the contralateral axilla and the arms are secured with padding. The patient is securely fastened with adequate padding to the operating room table using tape over the leg, thigh, pelvis, and chest. Flex the operating table to increase flank exposure (Fig. 1). Position the video monitors near the patient’s head. The surgeon and first assistant stand on the abdominal side of the patient. The second assistant stands on the side of the patient’s back (Fig. 2).

Fig. 1

Patient positioning

Fig. 2

Surgical team position [11]

Port Placement

Right Adrenalectomy [6]

• 1. Mark the anterior and posterior axillary lines before prepping the patient

• 2. Open technique is the preferred approach on entering the abdominal cavity using a blunt tipped cannula. Access to the peritoneal cavity may also be done using a closed technique with a Veress needle.

• 3. Insert first 10 mm trocar along anterior axillary line two fingers’ breadths below the costal margin.

• 4. The endoscope is then inserted and a diagnostic laparoscopy is performed. Look for signs of local invasion.

• 5. Under direct vision, insert second 5 mm trocar in the subcostal area medial to the first trocar. This port is for the graspers, energy devices, and peanut swabs used for dissection.

• 6. Insert the third 5 mm trocar between the anterior axillary line and the epigastrium. This will be used to retract the liver.

• 7. Insert the fourth 5 mm trocar at the subcostal triangle.

Left Adrenalectomy [6]

• 1. Mark the anterior and posterior axillary lines before prepping the patient.

• 2. Access peritoneal cavity using closed technique with Veress needle. Open technique may also be used using a blunt tipped cannula.

• 3. Insert first 10 mm trocar along anterior axillary line two fingers’ breadths below the costal margin.

• 4. The endoscope is then inserted and a diagnostic laparoscopy is performed. Look for signs of local invasion.

• 5. Two other 5 mm trocars are placed under direct vision about 7 cm on each side of the first trocar below the costal margin.

• 6. The fourth trocar, when necessary, is positioned below the first trocar at a distance of 4–5 cm.

Surgical Technique [6]

Right Adrenalectomy

Right Adrenalectomy is potentially more hazardous than left adrenalectomy due to the anatomy of the adrenal vein and its drainage to the inferior vena cava. Dissection of the right adrenal gland involves meticulous dissection of the lateral border to the inferior vena cava.

• 1. After pneumoperitoneum has been established, a 5 mm retractor is inserted through the most medial subcostal port to elevate the right lobe of the liver.

• 2. The right triangular ligament is dissected to achieve partial mobilization of the liver. Incise the posterior peritoneum along the inferior margin of the liver to expose the adrenal gland. The liver is then retracted upwards and medially to expose the adrenal gland and the inferior vena cava. The plane between the medial edge of the adrenal gland and the inferior vena cava is dissected (Fig. 3).

• 3. Dissection of the lateral edge of the vena cava should start from the right renal vein and head superiorly.

• 4. Identify the right adrenal vein. Dissect with right angle forceps and is doubly clipped and divided (Fig. 4).

• 5. Proceed to dissection of the inferior aspect of the adrenal en bloc with the periadrenal fat (Fig. 5).

• 6. The adrenal is then lifted up and the posterior, lateral, superior aspect of the gland is dissected (Fig. 6).

• 7. Identify and divide the three main adrenal arteries and accessory veins with energy devices. Typically, the adrenal arteries are not prominent and may not be intentionally identified.

• 8. Place the adrenal within a retrieval bag and remove it through the 10 mm trocar (Fig. 7).

• 9. Drain placement is optional. Port site closure is done.

Fig. 3

Division of right triangular ligament

Fig. 4

Dissection of medial border of the gland

Fig. 5

Isolation of R adrenal vein

Fig. 6

Dissection of the posterior aspect of the adrenal

Fig. 7

Placement of adrenal within a retrieval bag

Left Adrenalectomy

Several factors such as the lack of a major anatomic landmark, relatively small size of the left adrenal gland, main vein within the retroperitoneal fat, and close proximity to the pancreatic tail may render left adrenalectomy a challenging procedure. Careful dissection and mobilization of adjacent organs such as the spleen and pancreatic tail are needed to avoid injury.

• 1. Mobilization to the splenic flexure.

• 2. Division of the splenorenal ligament and rotate the spleen medially (Fig. 8).

• 3. Dissect the plane between the kidney and the tail of the pancreas and medially rotate the pancreas (Fig. 9).

• 4. Identify the adrenal gland near the superior and medial aspect of the kidney (Fig. 10).

• 5. Identify the medial and lateral borders of the gland and follow these borders caudally to the inferior margin of the gland where the adrenal vein lies.

• 6. Visualize the left renal vein during medial dissection and elevate the adrenal gland from this vessel.

• 7. Identify the left adrenal vein running obliquely from the inferomedial aspect of the adrenal gland to its junction with the left renal vein. Isolate and doubly clip and divide (Fig. 11).

• 8. Completely dissect the adrenal gland from the surrounding tissue.

• 9. Visualize and ligate with clips or with energy device arterial branches of the renal artery. The small adrenal arteries may not be easily identified but these are divided with the energy devices during the dissection of the adrenal gland.

• 10. Place the adrenal within a retrieval bag and remove it through the 10 mm trocar (Fig. 12).

• 11. Drain placement is optional. Port site closure is done.

Fig. 8

Dissection of the splenorenal ligament

Fig. 9

Medial rotation of the pancreatic tail

Fig. 10

Identification of the adrenal gland

Fig. 11

Identification of the L adrenal vein

Fig. 12

Placement of specimen in a retrieval bag

Post-op Management [6]

Most patients can be admitted to a regular surgical nursing unit. Patients with hemodynamically significant pheochromocytoma or major underlying cardiopulmonary disease should be admitted to an intensive care unit.

Diet may be advanced as tolerated. Oral analgesics may be taken 24 h postoperatively. A complete blood count and metabolic panel may be drawn as clinically indicated.

Most patients are discharged after 24–48 h without restrictions to physical activities. Patients may return to work within 7–14 days. A follow-up exam at the office should be performed 2–3 weeks after discharge. Patients are generally advised to avoid strenuous activities for 2–4 weeks.

For patients with hypercortisolism and those who undergo bilateral adrenalectomy, intravenous stress-dose corticosteroids are given in the immediate perioperative period. Once the patient resumes diet, intravenous doses may be stopped and replaced with oral corticosteroid therapy.

Patients with Cushing syndrome may require replacement therapy for 6–12 months while the contralateral gland recovers. This may be gradually tapered off as tolerated.

Complications

Complication rate for laparoscopic adrenalectomy ranges from 2.9% to 15.5% [7].

Hemorrhage [12]

Bleeding is the most prevalent intra-op and post-op complication considering the gland is highly vascularized and adjacent to major blood vessels. Intraoperative hemorrhage can be easily identified and may require conversion to an open procedure if hemostasis cannot be achieved. Postoperative bleeding is best detected by monitoring vital signs, urine output, and physical diagnosis of the abdomen.

Organ Injury [11]

The key to the prevention of inadvertent organ injury is familiarity with the anatomy and gentle dissection. Damage to the liver and spleen will present as intraoperative bleeding.

Care should be taken while dissecting the superior aspect of the left adrenal gland to prevent injury to the pancreatic tail. Damage to the pancreas can present early as pancreatitis or late as pancreatic pseudocyst. These can be self-limited but may require medical or surgical management.

High dissection in the abdomen may cause diaphragmatic injury, potentially leading to a tension pneumothorax. Closure with chest drainage would be the appropriate solution.

Others [11]

Appropriate pharmacologic blockade is mandatory before surgery of pheochromocytoma to prevent hypertensive crisis intraoperatively. Hemodynamic instability particularly hypertensive and hypotensive episodes (post-excision of tumor) may occur after laparoscopic adrenalectomy for pheochromocytoma. Sufficient hormonal replacement is mandatory after bilateral adrenalectomy in Cushing’s disease.