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Laparoscopic Left Adrenalectomy

  • Author: Michael S Lasser, MD; Chief Editor: Kurt E Roberts, MD  more...
 
Updated: Jun 19, 2015
 

Overview

Background

Laparoscopic left adrenalectomy is a procedure in which the adrenal gland is surgically removed. Adrenalectomy has undergone a significant transformation since the first report of a laparoscopic adrenalectomy was published in 1992.[1] Since that time, there has been a paradigm shift from open to laparoscopic approaches for both malignant and benign adrenal pathologies. The ascent of laparoscopy in adrenal surgery has been championed by numerous studies demonstrating a decreased blood loss, shorter hospital stay, shorter convalescence, and diminished patient morbidity when compared to open surgery.[2, 3, 4, 5, 6, 7]

The advance of laparoscopy has led to a surgical revolution that enabled surgeons to treat adrenal pathologies with decreased morbidity and allow patients the added benefit of an abbreviated convalescence. The use of laparoscopy in adrenal surgery is currently the standard of care and many new surgical approaches are actively being developed. Meticulous surgical dissection and increasing surgeon experience will help to maintain the current low complication rates.

Along with the popularization of laparoscopic adrenalectomy, there has been a surge in adrenal surgery. This is in part due to the identification of adrenal lesions on radiographic studies performed for unrelated indications, deemed the adrenal “incidentaloma.” Whereas patients with adrenal pathology previously presented with symptomatic disease, the diagnosis is now most commonly made after an adrenal lesion is diagnosed by means of computed tomography (CT). It is estimated that adrenal lesions are found in up to 5% of CT scans obtained for unrelated indications.[8] As a result of this increase in detection, the number of adrenalectomies increased 43% between 1988 and 2000.[9, 10]

Surgery is by no means indicated for all adrenal lesions. The differential diagnosis is broad and includes benign nonfunctional adenoma, functional adenoma, pheochromocytoma, myelolipoma, adrenocortical carcinoma, and metastatic lesions.

Indications

After an adrenal lesion is identified, it is imperative to determine the specific diagnosis. This is critical as the indications for adrenalectomy are twofold: tumor functionality and malignant potential.

When an adrenal lesion is identified, the first question that needs to be addressed is whether or not the lesion is hormonally active. Adrenal lesions can secrete cortisol (Cushing syndrome), aldosterone (Conn syndrome), or catecholamines (pheochromocytoma). The chart below lists several tests used to determine the functionality of an adrenal pathology.

Tests to determine the functionality of an adrenal Tests to determine the functionality of an adrenal pathology.

When an adrenal lesion is determined to be hormonally active, extirpative therapy is indicated.

The malignant potential of a lesion correlates well with its size.[11] Specifically, when radiographic and pathologic data are examined, approximately 95% of adrenocortical carcinomas are more than 5 cm in diameter.[12, 13] As such, it is generally recommended that all lesions 5 cm or larger be considered adrenocortical carcinoma and excision is recommended.[14]

Contraindications

Initially, open adrenalectomy was preferred in cases of suspected adrenocortical carcinoma. Today, however, there are few absolute contraindications to laparoscopic adrenalectomy. Laparoscopic approaches to the treatment of all adrenal pathologies have been successfully performed.[4, 15, 16, 17] As experience with laparoscopic adrenalectomy has increased, the absolute contraindications have dwindled.

Today, laparoscopic adrenalectomy has been contraindicated in lesions 12 cm and larger.[17, 18] Despite this, however, the laparoscopic approach has been used in large adrenal masses up to 17 cm. In a report by Boylu et al,[19] the use of the laparoscopic approach in lesions greater than 8 cm resulted in longer operative times and higher blood loss but was comparable when hospital stay, open conversion rate, and pathologic outcome were compared.

As a result, the only absolute contraindication to laparoscopic adrenalectomy in experienced hands is suspected adrenocortical carcinoma with extension into surrounding organs. In this setting, the open approach facilitates an en-bloc excision of all involved viscera and increased chance of cure.[20, 21]

Technical considerations

Procedural planning

Throughout the literature, there are a plethora of papers describing surgical techniques used in extirpative therapy for adrenal lesions. The two most commonly used laparoscopic approaches are transperitoneal and retroperitoneal. Additionally, several authors have documented their experience with robot-assisted,[22] laparoendoscopic single-site,[23, 24, 25, 26] natural orifice,[27] and transthoracic[28] techniques.

Most of the aforementioned approaches to adrenalectomy are in their infancy, with only the initial experiences of select surgeons documented. The two most commonly used approaches remain transperitoneal and retroperitoneal laparoscopic adrenalectomy, each of which has its own inherent benefits and shortcomings. Some authors have found the retroperitoneal approach to be faster and associated with lower blood loss in the setting of pheochromocytoma.[29] Others have attempted to exclude adrenal pathology as a confounding factor and have documented transperitoneal to be faster with a shorter learning curve.[30]

Despite this, surgeon preference and experience are the most important factors impacting surgical technique selection. The vast majority of the literature does not demonstrate any significant advantages when the two approaches are directly compared.[30, 31, 32, 33, 34]

The transperitoneal approach more closely mirrors the open approach to adrenalectomy and is the approach used at our institution. Therefore, this topic concentrates on transperitoneal laparoscopic left adrenalectomy.

Complication prevention

Several adrenal pathologies require extirpative management. Each of the individual pathologies carries risks that require attention preoperatively, intraoperatively, and postoperatively.

Careful preoperative evaluation of patients with hormonally active adrenal lesions is critical. It is imperative that the surgeon has an understanding of adrenal physiology. Additionally, the consultation of anesthesiology, endocrinology, and (in some instances) cardiology is often helpful preoperatively.

Patients with pheochromocytoma represent a uniquely difficult cohort. Preoperatively, these patients require pharmacologic alpha-adrenergic blockade, and often the addition of beta-adrenergic blockade, for adequate blood pressure management. Additionally, these patients tend to be significantly volume depleted and can suffer from cathecholamine-induced cardiomyopathy. The judicious use of alpha blockers preoperatively can facilitate the expansion of blood volume in these patients in a controlled fashion.

In addition to the adrenal-specific concerns, patients require standard precautions preoperatively. Patients should receive a mechanical bowel preparation with only clear liquids on the day prior to surgery. Broad-spectrum perioperative antibiotics should be administered within 1 hour of incision and standard deep vein thrombosis prophylaxis with stockings and pneumatic compression devices with or without subcutaneous heparin should be initiated prior to the induction of anesthesia.

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Periprocedural Care

Patient preparation

The patient is placed into the right lateral decubitus position (left side up) at approximately 60-90º. All pressure points are adequately padded, an axillary role is placed, the bed is flexed, the kidney rest is elevated just cephalad to the level of the iliac crest, the arms are secured into the anatomic position with adequate padding, and the patient is secured to the table. The use of a beanbag can facilitate positioning and provide an additional layer of security when securing the patient to the surgical table. Importantly, the beanbag should not be deflated until the bed is flexed and the patient is adequately positioned.

The use of this lateral decubitus positioning allows the intra-abdominal viscera to fall away from the adrenal gland to facilitate dissection and provides for maximal opening of the space between the iliac crest and the costal margin for trocar placement. Open conversion, if necessary, will be facilitated by the use of this positioning.

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Technique

Approach considerations

Throughout the literature, there are a plethora of papers describing surgical techniques used in extirpative therapy for adrenal lesions. The two most commonly used laparoscopic approaches are transperitoneal and retroperitoneal. Additionally, several authors have documented their experience with robot-assisted,[22] laparoendoscopic single-site,[23, 24, 25, 26] natural orifice,[27] and transthoracic[28] techniques.

Most of the aforementioned approaches to adrenalectomy are in their infancy, with only the initial experiences of select surgeons documented. The two most commonly used approaches to laparoscopic adrenalectomy remain the transperitoneal and the retroperitoneal, each of which has its own inherent benefits and shortcomings. Some authors have found the retroperitoneal approach to be faster and associated with lower blood loss in the setting of pheochromocytoma.[29] Others have attempted to exclude adrenal pathology as a confounding factor and have documented transperitoneal to be faster with a shorter learning curve.[30]

Despite this, surgeon preference and experience are the most important factors impacting surgical technique selection. The vast majority of the literature does not demonstrate any significant advantages when the transperitoneal and retroperitoneal approaches are directly compared.[30, 31, 32, 33, 34]  Some experience suggests that a single-incision laparoscopic approach to left adrenalectomy may yield results comparable to those of a conventional laparoscopic approach.[26]

The transperitoneal approach more closely mirrors the open approach to adrenalectomy and is the approach used at our institution. In this topic, we concentrate on the transperitoneal left laparoscopic adrenalectomy.

Transperitoneal approach

After the induction of anesthesia and adequate positioning, trocar placement is performed. Three subcostal ports are used for the left laparoscopic transperitoneal adrenalectomy. Initially pneumoperitoneum is established via either the Veress needle or the open Hasson technique. Trocar placement into a semilunar configuration is recommended (see the image below).

Left laparoscopic adrenalectomy trocar placement. Left laparoscopic adrenalectomy trocar placement.

We prefer two 5-mm ports placed in the midclavicular line with a third 12-mm trocar placed in the anterior axillary line superior to the plane of the umbilicus. We recommend diagnostic laparoscopy after initial trocar placement to rule out intraperitoneal visceral injury, bleeding, or adhesions and additional trocar placement under visual guidance.

Peritoneal adhesions are divided and the procedure is commenced. Key anatomic landmarks to identify include the spleen, splenic flexure of the colon, tail of the pancreas, the left kidney, and the fundus of the stomach. The splenic flexure and descending colon are mobilized medially and the lateral attachments of the spleen are divided.

Once the splenocolic and lienorenal ligaments are divided, the spleen is easily mobilized medially and adequate exposure of the adrenal gland is achieved. An added benefit of splenic mobilization is its propensity to pull the tail of the pancreas medially, therefore decreasing the likelihood of inadvertent pancreatic injury. It is important to note that dissection lateral to the kidney should be avoided, in that it may allow the Gerota fascia to fall medially, making the adrenal dissection more difficult.

Once adequate exposure is attained, the adrenal dissection can commence. The initial step in resection of the adrenal gland is the identification and ligation of the adrenal vein. This can reliably be achieved via identification of the renal vein. An incision into the Gerota fascia over the upper pole of the kidney allows for medial dissection towards the renal vein.

Once visualized, careful dissection along the cephalad border of the vein will allow for identification and subsequent ligation of the adrenal vein. Given the complicated arterial supply of the adrenal gland, a distinct adrenal artery is rarely encountered. Rather, the adrenal gland is circumferentially dissected with the use of an energy-based hemostatic device. Both the Harmonic Scalpel (Ethicon Endosurgery) and the Ligasure (Tyco Valleylab) have been described in this setting with equal efficacy.[35, 36]

The specimen is then removed intact via a retrieval bag. If there is a question of adequate dissection margins, frozen section pathologic analysis can be obtained prior to closure. Pneumoperitoneum is decreased to 5 mm Hg to assess hemostasis; once assured, the pneumoperitoneum is released and trocar sites closed.

Complications

Complications of laparoscopic surgery have been well studied and documented throughout the literature. The complications of left laparoscopic adrenalectomy specifically, however, are somewhat lacking. Gupta et al reviewed the National Surgical Quality Improvement program for all patients undergoing laparoscopic adrenalectomy between 2007 and 2008.[37] Multivariate analysis demonstrated an increased risk of postoperative complications in those patients with significant peripheral vascular disease and poor functional status.

The most common complication encountered during laparoscopic adrenalectomy is vascular injury. In a metanalysis, Strebel et al determined that the overall incidence of vascular injury is low at 0.7-5.4%, but the reported transfusion rates are significantly higher at 10%.[38] These injuries can be access or dissection related. Additionally, bleeding complications tend to occur when adequate exposure has not been obtained and are more prevalent in complex procedures.

During left laparoscopic adrenalectomy, the spleen and tail of the pancreas are within the field of dissection and therefore are at risk of injury. The spleen is a particularly fragile organ and care must be taken during its dissection and retraction. The specific rate of splenic injury during adrenalectomy is not available. Using laparoscopic nephrectomy as a surrogate, however, splenic injury occurs in approximately 0.5-1.3% cases.[39]

As with other laparoscopic procedures, additional complications can occur. Reports of injury of the small bowel, colon, diaphragm, pleura, and liver have been described.[40, 41] In a retrospective review of 163 patients undergoing laparoscopic adrenalectomy, Rieder et al found an overall complication rate of 3.7%.[15] In this report, the complications included pneumothorax, pulmonary embolism, and congestive heart failure.

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Contributor Information and Disclosures
Author

Michael S Lasser, MD Medical Director of Robotic Surgery, Center for Robotic Surgery, Jersey Shore University Medical Center, Neptune, NJ

Michael S Lasser, MD is a member of the following medical societies: American Urological Association, Rhode Island Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

David M Hoenig, MD Chief of Urology, Long Island Jewish Medical Center

David M Hoenig, MD is a member of the following medical societies: American Urological Association, Endourological Society

Disclosure: Received honoraria from Best Doctors Inc for consulting.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

References
  1. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing's syndrome and pheochromocytoma. N Engl J Med. 1992 Oct 1. 327(14):1033. [Medline].

  2. Brunt LM, Doherty GM, Norton JA, Soper NJ, Quasebarth MA, Moley JF. Laparoscopic adrenalectomy compared to open adrenalectomy for benign adrenal neoplasms. J Am Coll Surg. 1996 Jul. 183(1):1-10. [Medline].

  3. Hazzan D, Shiloni E, Golijanin D, Jurim O, Gross D, Reissman P. Laparoscopic vs open adrenalectomy for benign adrenal neoplasm. Surg Endosc. 2001 Nov. 15(11):1356-8. [Medline].

  4. Assalia A, Gagner M. Laparoscopic adrenalectomy. Br J Surg. 2004 Oct. 91(10):1259-74. [Medline].

  5. Schell SR, Talamini MA, Udelsman R. Laparoscopic adrenalectomy for nonmalignant disease: improved safety, morbidity, and cost-effectiveness. Surg Endosc. 1999 Jan. 13(1):30-4. [Medline].

  6. Winfield HN, Hamilton BD, Bravo EL, Novick AC. Laparoscopic adrenalectomy: the preferred choice? A comparison to open adrenalectomy. J Urol. 1998 Aug. 160(2):325-9. [Medline].

  7. Yoshimura K, Yoshioka T, Miyake O, Matsumiya K, Miki T, Okuyama A. Comparison of clinical outcomes of laparoscopic and conventional open adrenalectomy. J Endourol. 1998 Dec. 12(6):555-9. [Medline].

  8. Grumbach MM, Biller BM, Braunstein GD, et al. Management of the clinically inapparent adrenal mass ("incidentaloma"). Ann Intern Med. 2003 Mar 4. 138(5):424-9. [Medline].

  9. Saunders BD, Wainess RM, Dimick JB, Upchurch GR, Doherty GM, Gauger PG. Trends in utilization of adrenalectomy in the United States: have indications changed?. World J Surg. 2004 Nov. 28(11):1169-75. [Medline].

  10. Murphy MM, Witkowski ER, Ng SC, et al. Trends in adrenalectomy: a recent national review. Surg Endosc. 2010 Oct. 24(10):2518-26. [Medline].

  11. Hussain S, Belldegrun A, Seltzer SE, Richie JP, Gittes RF, Abrams HL. Differentiation of malignant from benign adrenal masses: predictive indices on computed tomography. AJR Am J Roentgenol. 1985 Jan. 144(1):61-5. [Medline].

  12. Schteingart DE, Doherty GM, Gauger PG, et al. Management of patients with adrenal cancer: recommendations of an international consensus conference. Endocr Relat Cancer. 2005 Sep. 12(3):667-80. [Medline].

  13. Belldegrun A, Hussain S, Seltzer SE, Loughlin KR, Gittes RF, Richie JP. Incidentally discovered mass of the adrenal gland. Surg Gynecol Obstet. 1986 Sep. 163(3):203-8. [Medline].

  14. Bornstein SR, Stratakis CA, Chrousos GP. Adrenocortical tumors: recent advances in basic concepts and clinical management. Ann Intern Med. 1999 May 4. 130(9):759-71. [Medline].

  15. Rieder JM, Nisbet AA, Wuerstle MC, Tran VQ, Kwon EO, Chien GW. Differences in left and right laparoscopic adrenalectomy. JSLS. 2010 Jul-Sep. 14(3):369-73. [Medline]. [Full Text].

  16. Shen WT, Grogan R, Vriens M, Clark OH, Duh QY. One hundred two patients with pheochromocytoma treated at a single institution since the introduction of laparoscopic adrenalectomy. Arch Surg. 2010 Sep. 145(9):893-7. [Medline].

  17. Brix D, Allolio B, Fenske W, et al. Laparoscopic versus open adrenalectomy for adrenocortical carcinoma: surgical and oncologic outcome in 152 patients. Eur Urol. 2010 Oct. 58(4):609-15. [Medline].

  18. Gumbs AA, Gagner M. Laparoscopic adrenalectomy. Best Pract Res Clin Endocrinol Metab. 2006 Sep. 20(3):483-99. [Medline].

  19. Boylu U, Oommen M, Lee BR, Thomas R. Laparoscopic adrenalectomy for large adrenal masses: pushing the envelope. J Endourol. 2009 Jun. 23(6):971-5. [Medline].

  20. Schulick RD, Brennan MF. Long-term survival after complete resection and repeat resection in patients with adrenocortical carcinoma. Ann Surg Oncol. 1999 Dec. 6(8):719-26. [Medline].

  21. Schulick RD, Brennan MF. Adrenocortical carcinoma. World J Urol. 1999 Feb. 17(1):26-34. [Medline].

  22. Boris RS, Gupta G, Linehan WM, Pinto PA, Bratslavsky G. Robot-assisted laparoscopic partial adrenalectomy: initial experience. Urology. 2011 Apr. 77(4):775-80. [Medline]. [Full Text].

  23. Chung SD, Huang CY, Wang SM, Tai HC, Tsai YC, Chueh SC. Laparoendoscopic single-site (LESS) retroperitoneal adrenalectomy using a homemade single-access platform and standard laparoscopic instruments. Surg Endosc. 2011 Apr. 25(4):1251-6. [Medline].

  24. Zhang X, Shi TP, Li HZ, Ma X, Wang BJ. Laparo-endoscopic single site anatomical retroperitoneoscopic adrenalectomy using conventional instruments: initial experience and short-term outcome. J Urol. 2011 Feb. 185(2):401-6. [Medline].

  25. Cindolo L, Gidaro S, Neri F, Tamburro FR, Schips L. Assessing feasibility and safety of laparoendoscopic single-site surgery adrenalectomy: initial experience. J Endourol. 2010 Jun. 24(6):977-80. [Medline].

  26. Vidal O, Astudillo E, Valentini M, Ginestá C, Espert JJ, Gracía-Valdecasas JC, et al. Single-port laparoscopic left adrenalectomy (SILS): 3 years' experience of a single institution. Surg Laparosc Endosc Percutan Tech. 2014 Oct. 24 (5):440-3. [Medline].

  27. Perretta S, Allemann P, Asakuma M, Dallemagne B, Marescaux J. Adrenalectomy using natural orifice translumenal endoscopic surgery (NOTES): a transvaginal retroperitoneal approach. Surg Endosc. 2009 Jun. 23(6):1390. [Medline].

  28. Gill IS, Meraney AM, Thomas JC, Sung GT, Novick AC, Lieberman I. Thoracoscopic transdiaphragmatic adrenalectomy: the initial experience. J Urol. 2001 Jun. 165(6 Pt 1):1875-81. [Medline].

  29. Li QY, Li F. Laparoscopic adrenalectomy in pheochromocytoma: retroperitoneal approach versus transperitoneal approach. J Endourol. 2010 Sep. 24(9):1441-5. [Medline].

  30. Gockel I, Kneist W, Heintz A, Beyer J, Junginger T. Endoscopic adrenalectomy: an analysis of the transperitoneal and retroperitoneal approaches and results of a prospective follow-up study. Surg Endosc. 2005 Apr. 19(4):569-73. [Medline].

  31. Rubinstein M, Gill IS, Aron M, et al. Prospective, randomized comparison of transperitoneal versus retroperitoneal laparoscopic adrenalectomy. J Urol. 2005 Aug. 174(2):442-5; discussion 445. [Medline].

  32. Tai CK, Li SK, Hou SM, Fan CW, Fung TC, Wah MK. Laparoscopic adrenalectomy: Comparison of lateral transperitoneal and lateral retroperitoneal approaches. Surg Laparosc Endosc Percutan Tech. 2006 Jun. 16(3):141-5. [Medline].

  33. Naya Y, Nagata M, Ichikawa T, et al. Laparoscopic adrenalectomy: comparison of transperitoneal and retroperitoneal approaches. BJU Int. 2002 Aug. 90(3):199-204. [Medline].

  34. Berber E, Tellioglu G, Harvey A, Mitchell J, Milas M, Siperstein A. Comparison of laparoscopic transabdominal lateral versus posterior retroperitoneal adrenalectomy. Surgery. 2009 Oct. 146(4):621-5; discussion 625-6. [Medline].

  35. Sartori PV, Romano F, Uggeri F, et al. Energy-based hemostatic devices in laparoscopic adrenalectomy. Langenbecks Arch Surg. 2010 Feb. 395(2):111-4. [Medline].

  36. Surgit O. Clipless and sutureless laparoscopic adrenalectomy carried out with the LigaSure device in 32 patients. Surg Laparosc Endosc Percutan Tech. 2010 Apr. 20(2):109-13. [Medline].

  37. Gupta PK, Natarajan B, Pallati PK, Gupta H, Sainath J, Fitzgibbons RJ Jr. Outcomes after laparoscopic adrenalectomy. Surg Endosc. 2011 Mar. 25(3):784-94. [Medline].

  38. Strebel RT, Müntener M, Sulser T. Intraoperative complications of laparoscopic adrenalectomy. World J Urol. 2008 Dec. 26(6):555-60. [Medline].

  39. Pareek G, Hedican SP, Gee JR, Bruskewitz RC, Nakada SY. Meta-analysis of the complications of laparoscopic renal surgery: comparison of procedures and techniques. J Urol. 2006 Apr. 175(4):1208-13. [Medline].

  40. Henry JF, Defechereux T, Raffaelli M, Lubrano D, Gramatica L. Complications of laparoscopic adrenalectomy: results of 169 consecutive procedures. World J Surg. 2000 Nov. 24(11):1342-6. [Medline].

  41. Nau P, Demyttenaere S, Muscarella P, et al. Pheochromocytoma does not increase risk in laparoscopic adrenalectomy. Surg Endosc. 2010 Nov. 24(11):2760-4. [Medline].

 
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Left laparoscopic adrenalectomy trocar placement.
Tests to determine the functionality of an adrenal pathology.
 
 
 
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