Background
Laparoscopic left adrenalectomy is a procedure in which the left adrenal gland is surgically removed. Adrenalectomy has undergone a significant transformation since the first report of a laparoscopic adrenalectomy was published in 1992. [1] 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 decreased blood loss, shorter hospital stays, shorter convalescence, and diminished patient morbidity with laparoscopic surgery as compared with 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 offered 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 being actively developed. Meticulous surgical dissection and increasing surgeon experience will help maintain the current low complication rates.
Along with the popularization of laparoscopic adrenalectomy, there has been a surge in adrenal surgery overall. This is in part due to the identification of adrenal lesions on radiographic studies performed for unrelated indications (adrenal “incidentalomas”). Whereas patients with adrenal pathology previously presented with symptomatic disease, the diagnosis is now most commonly made after an adrenal lesion is diagnosed via computed tomography (CT). It is estimated that adrenal lesions are found in as many as 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, in that the indications for adrenalectomy are twofold: tumor functionality and malignant potential.
When an adrenal lesion is identified, the first question 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.
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, for which excision is recommended. [14]
Contraindications
Initially, open adrenalectomy was preferred in cases of suspected adrenocortical carcinoma. Today, however, there are few absolute contraindications for 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.
In practice, laparoscopic adrenalectomy has generally been contraindicated in lesions 12 cm and larger. [17, 18] Nevertheless, 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 larger than 8 cm resulted in longer operating times and higher blood loss but was comparable when hospital stay, open conversion rate, and pathologic outcome were compared.
As a result, it has generally been considered that the only absolute contraindication for 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 affords an increased chance of cure. [20, 21]
A review of 13 nonrandomized studies (N = 1171) found that laparoscopic adrenalectomy appeared to be equivalent to open adrenalectomy for localized or locally advanced primary adrenocortical carcinoma (European Network for the Study of Adrenal Tumors [ENSAT] I-III) in terms of R0 resection rate, overall recurrence, disease-free survival, and overall survival. [22]
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, [23, 24, 25, 26] laparoendoscopic single-site, [27, 28, 29, 30, 31, 32] natural orifice, [33] and transthoracic [34] techniques. A mini-laparoscopic approach combined with transgastric specimen extraction has also been described. [35]
Most of the aforementioned approaches to adrenalectomy are not long established, 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. [36] Others have attempted to exclude adrenal pathology as a confounding factor and have found transperitoneal to be faster with a shorter learning curve. [37] 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. [37, 38, 39, 40, 41]
The transperitoneal approach more closely mirrors the open approach to adrenalectomy and is the approach used at our institution. Accordingly, this topic concentrates on transperitoneal laparoscopic left adrenalectomy.
Some experience suggests that a single-incision laparoscopic approach to left adrenalectomy may yield results comparable to those of a conventional laparoscopic approach. [30] A study by Piccoli et al found the outcomes of robotic adrenalectomy to be similar to those of laparoscopic adrenalectomy and suggested that the robotic approach may yield greater benefits on the left than on the right. [23]
Complication prevention
Several adrenal pathologies necessitate 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 before surgery. Broad-spectrum perioperative antibiotics should be administered within 1 hour of incision, and standard deep vein thrombosis (DVT) 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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Laparoscopic transabdominal left adrenalectomy. Procedure performed by James Lee, MD, ColumbiaDoctors, New York, NY. Video courtesy of ColumbiaDoctors (https://www.columbiadoctors.org).
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Laparoscopic left adrenalectomy: trocar placement.
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Tests to determine functionality of adrenal pathology.
