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Laparoscopic Adrenalectomy

Deepraj S Bhandarkar
 

Introduction
Adrenal glands are vascular organs situated in the retroperitoneal location in close proximity to important vessels and viscera. Traditionally, open adrenalectomy (OA) performed through transperitoneal or retroperitoneal approaches required long incisions; these long incisions were the cause of postoperative pain and morbidity. Since the advent of laparoscopic cholecystectomy around 1989, this technique has been applied to several other areas - laparoscopic adrenalectomy (LA) being one of them.

Historical Background
Table 1 enlists the historical landmarks in the development of LA.

Indications
The indications for LA remain the same as those for OA. The indications for LA may be summarised as follows:

a) Functioning adrenal tumours
Unilateral adrenalectomy
Cortisol secreting adenomas of adrenal gland
Aldosterone secreting adenomas (Conn’s syndrome)
Virilizing adrenal tumours
Phaeochromocytoma
Bilateral adrenalectomy
Bilateral adrenal hyperplasia (in patients with pituitary lesions who have failed to respond to previous pituitary surgery / ablation)
Cushing’s syndrome due to ectopic ACTH secretion unresponsive to medical therapy
b) Nonfunctioning adrenal tumours
Incidentalomas (adrenal tumours detected incidentally) which are more than 4 cm in size
Incidentalomas which are shown to be increasing in size on serial imaging
Solitary adrenal metastasis from other malignancy
c) Rare conditions
Myelolipomas
Adrenal cysts
Adrenal tuberculosis

Contraindications
The definite contraindications to LA are unacceptable cardiopulmonary risk, uncontrolled coagulopathy and patients with known adrenocortical carcinoma with tumour invasion to adjacent viscera. LA for suspected adrenocortical carcinoma remains a controversial indication. Obesity and previous abdominal surgery are no longer considered contraindications. In patients with previous abdominal surgery, a retroperitoneoscopic adrenalectomy (RA) may form a valid treatment option. Large tumours (> 10 cm) form a relative contraindication for two reasons: a) Larger tumours carry a higher risk of being malignant and b) These are more difficult to handle laparoscopically making the vascular control more challenging to obtain as well as increasing the chances of intraoperative spillage.

Preoperative Preparation
A detailed discussion regarding the preoperative preparation of patients undergoing LA is out of the purview of this review. Those suffering from hypercortisolism or hyperaldosteronism often tend to have electrolyte imbalance, other metabolic problems and hypertension that need careful evaluation and correction before surgery. Patients with phaeochromocytoma undergoing surgery require the most meticulous planning and control of blood pressure. A smooth peri-operative course in patients with phaeochromocytoma undergoing LA depends as much on the adequacy and diligence of the preoperative preparation as the meticulousness of the surgery itself.

Surgical Technique
Laparoscopic adrenalectomy
For LA the patient is positioned in lateral position with the side of lesion uppermost. Four ports (5 mm – 10 mm in size) are established. For the left adrenalectomy the spleen and the pancreas are mobilised extensively and the adrenal gland / tumour is identified as a golden yellow organ in surrounding pale yellow retroperitoneal fat. The adrenal vein is controlled (Fig. 1) and divided first followed by control of the rest of the vasculature to the gland. Use of specialised equipment such as ultrasonic shears allows the surgeon to perform a relatively bloodless and precise dissection. Once the gland is completely dissected, it is placed in a plastic bag and the tumour is extracted without spillage by enlarging the site of one of the ports.


Fig. 1 : Clipping of left adrenal vein during laparoscopic
adrenalectomy for a left phaeochromocytoma

During right LA, the right lobe of liver is retracted superiorly, the peritoneum along its inferior edge is incised. The inferior vena cava is identified and traced upwards. The short, stumpy right adrenal vein draining directly into the cava requires careful dissection and control. Following this crucial step, rest of the vessels are controlled and the gland dissected free from the surrounding structures. As for the left side, the specimen is always extracted after its placement in an impervious bag.

Retroperitoneoscopic adrenalectomy
Surgeons / urologists more familiar with the retroperitoneal approach prefer to create a space in the retroperitoneum (left or right) by introduction of a balloon. Trocars are placed in this space and the respective adrenal gland is dissected free after control of its vasculature.

Postoperative Course
After LA, the postoperative recovery of the patient is quite rapid. Typically, a patient may be able to get discharged two to four days after surgery and return to normal activity a week to ten days later. Patients who have severe preoperative metabolic disturbances form an exception to this and may require a longer hospitalisation and convalescence. A recent review analysing several series of patients (N = 2550) undergoing LA puts the overall complication rate associated with LA at 9.5% (range 2.5% – 20%) and the mortality at 0.2% (range 0% – 1.2%).8

Laparoscopic versus Open Adrenalectomy
Several authors have compared LA and OA and reported their observations.8 The reported benefits of LA are:

Reduced intraoperative blood loss
Reduced postoperative requirement for analgesia
Shorter hospital stay

The incidence of injury to organs (commonly spleen) is said to be higher after OA as also the incidence of cardiac, pulmonary and wound complications.

A recent NIH consensus and state-of-the-science statement on management of adrenal incidentalomas9 outlines the advantages of LA as:
1) decreased postoperative pain,
2) reduced time to return of bowel function,
3) decreased length of hospital stay and
4) the potential for earlier return to work.

Current Status and Future Directions
When LA is carried out by surgeons experienced in advanced laparoscopic surgery at institutions with adequate backup for perioperative care, it carries a favourable outcome for the patient. In the relatively short period after its introduction, LA has virtually replaced OA except for indications such as known adrenocortical carcinoma or large tumours and represents the “gold standard” the world over in treatment of adrenal disorders.

New minimally invasive, adrenal-sparing procedures have recently been introduced recently, among them are laparoscopic partial adrenalectomy, cryosurgery, and radiofrequency ablation.10 Cortical-sparing laparoscopic partial adrenalectomy reserved for patients with small, well circumscribed and peripherally located lesions – commonly unilateral aldosteronomas11 or phaeochrmocytomas12 in patients with multiple endocrine neoplasia (MEN) syndrome. However, issues related to the risks and benefits associated with adrenal-sparing surgery as yet remain unresolved.

References

  1. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med 1992; 327 : 1033.
  2. Gagner M, Lacroix A, Prinz RA, et al. Early experience with laparoscopic approach for adrenalectomy. Surgery 1993; 114 : 1120-4.
  3. Fernandez-Cruz L, Benarroch G, Torres E, et al. Laparoscopic approach to the adrenal tumors. J Laparoendosc Surg 1993; 3 : 541-6.
  4. Ushiyama T, Suzuki K, Kageyama S, et al. A case of Cushing’s syndrome due to adrenocortical carcinoma with recurrence 19 months after laparoscopic adrenalectomy. J Urol 1997; 157 : 2239.
  5. Gagner M, Garcia-Ruiz A. Technical aspects of minimally invasive abdominal surgery performed with needlescopic instruments. Surg Laparosc Endosc 1998; 8 : 171-9.
  6. Gill IS, Soble JJ, Sung GT, et al. Needlescopic adrenalectomy—the initial series: comparison with conventional laparoscopic adrenalectomy. Urology 1998; 52 : 180-6.
  7. Edwin B, Raeder I, Trondsen E, et al. Outpatient laparoscopic adrenalectomy in patients with Conn’s syndrome. Surg Endosc 2001; 15 : 589-91.
  8. Assalia A, Gagner M. Laparoscopic adrenalectomy. Br J Surg 2004; 91 : 1259-74.
  9. NIH state-of-the-science statement on management of the clinically inapparent adrenal mass (“incidentaloma”). NIH Consens State Sci Statements. 2002; 19 : 1-25.
  10. Munver R, Del Pizzo JJ, Sosa RE. Adrenal-preserving minimally invasive surgery: the role of laparoscopic partial adrenalectomy, cryosurgery, and radiofrequency ablation of the adrenal gland. Curr Urol Rep 2003; 4 : 87-92.
  11. Ishidoya S, Ito A, Sakai K, et al. Laparoscopic partial versus total adrenalectomy for aldosterone producing adenoma. J Urol 2005; 174 : 40-3.
  12. Nambirajan T, Leeb K, Neumann HP, et al. Laparoscopic adrenal surgery for recurrent tumours in patients with hereditary phaeochromocytoma. Eur Urol 2005; 47 : 622-6.

 
Minimal Access Surgeon, Department of Minimal Access Surgery, P D Hinduja National Hospital and Medical Research Centre, Mumbai and Laparoscopic and GI Surgeon, Sir Hurkisondas Nurrotumdas Hospital, Mumbai.
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