Laparoscopic Left Adrenalectomy

Laparoscopic left adrenalectomy is a procedure in which the left adrenal (suprarenal) 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. Laparoscopy is currently the standard of care in adrenal surgery, and many new surgical approaches are being actively developed. Meticulous surgical dissection and increasing surgeon experience will help maintain the current low complication rates.

The popularization of laparoscopic adrenalectomy has been accompanied by 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 has been estimated that adrenal lesions are found in as many as 5% of CT scans obtained for unrelated indications.[8]  As a result of increased 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.

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]  Accordingly, it is generally recommended that all lesions 5 cm or larger be considered adrenocortical carcinoma, for which excision is recommended.[14]

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]

Procedural planning

Throughout the literature, there are numerous 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, 27] laparoendoscopic single-site,[28, 29, 30, 31, 32, 33] natural orifice,[34] and transthoracic[35] techniques. A minilaparoscopic approach combined with transgastric specimen extraction has also been described.[36]

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.[37] Others have attempted to exclude adrenal pathology as a confounding factor and have found the transperitoneal approach to be faster with a shorter learning curve.[38]  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.[38, 39, 40, 41, 42]

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.[31]  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.[24]

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.

A systematic review and meta-analysis by Wang et al (five studies; N = 780) compared the outcomes of laparoscopic right (n = 361) and left (n = 419) adrenalectomy.[43]  Laparoscopic left adrenalectomy was found to be associated with a lower risk of bleeding and a lower conversion rate.

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 the patient is being secured to the surgical table. The beanbag should not be deflated until the bed is flexed and the patient adequately positioned.

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

Although several authors have documented their experience with robot-assisted,[26, 23] laparoendoscopic single-site,[28, 29, 30, 31] natural orifice,[34] and transthoracic[35] techniques, 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.

The vast majority of the literature has not shown either of these two approaches to have any significant advantages over the other.[38, 39, 40, 41, 42, 44] The transperitoneal approach more closely mirrors the open approach to adrenalectomy and is the one used at our institution; for this reason, it is the focus of the subsequent discussion. Variations of the transperitoneal approach have been described, including lateral transperitoneal,[45] anterior transperitoneal, and anterior transperitoneal submesocolic.[46]

The video below illustrates a laparoscopic transabdominal left adrenalectomy.

After the induction of anesthesia and adequate positioning, trocar placement is performed. Three subcostal ports are used for a laparoscopic transperitoneal left 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).

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; additional trocars can then be placed under visual guidance. Intraoperative laparoscopic ultrasonography (US) may be helpful for enhancing visualization and facilitating dissection.[47]

Peritoneal adhesions are divided, and the procedure is commenced. Key anatomic landmarks to identify include the spleen, the splenic flexure of the colon, the tail of the pancreas, the left kidney, and the fundus of the stomach. The splenic flexure and the 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, thereby 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 to identify and ligate 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 medial dissection towards the renal vein.

Once visualization is achieved, careful dissection along the cephalad border of the vein will allow 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, Cincinnati, OH) and the Ligasure (Tyco Valleylab, Boulder, CO) have been used in this setting, with equal efficacy reported.[48, 49]  The Thunderbeat (Olympus Europa, Hamburg, Germany) has been reported to be effective for adrenal surgery as well.[50]

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 permit assessment of hemostasis; once hemostasis is assured, the pneumoperitoneum is released and the trocar sites closed.

Complications of laparoscopic surgery in general have been well studied and documented throughout the literature. Studies of the specific complications of laparoscopic left adrenalectomy, however, are somewhat lacking. Gupta et al reviewed the National Surgical Quality Improvement Program (NSQIP) database for all patients undergoing laparoscopic adrenalectomy between 2007 and 2008.[51]  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 (0.7-5.4%) but the reported transfusion rates are significantly higher (10%).[52]  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 laparoscopic left 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 has not been determined. When laparoscopic nephrectomy is used as a surrogate, however, it can be estimated that splenic injury occurs in approximately 0.5-1.3% cases.[53]  So-called wandering spleen may occur but generally appears to be an isolated complication.[54]

As with other laparoscopic procedures, additional complications can occur. Reports of injury to the small bowel, colon, diaphragm, pleura, and liver have been described.[55, 56]  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.

A single-center study by Girón et al suggested that in patients undergoing minimally invasive adrenalectomy, higher body mass index (BMI) may be associated with higher postoperative antihypertensive drug use, and greater tumor volume may be associated with longer operating time and greater blood loss.[57]