Approach Considerations
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.
Transperitoneal Approach to Laparoscopic 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
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]
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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.
