Background
Perhaps no organ is better suited for laparoscopic surgery than the adrenal gland, by reason of its small size and its relatively difficult location in the retroperitoneum, which requires a large open excision for extraction. Since the first description of laparoscopic adrenalectomy by Gagner et al in 1992, [1] this approach has become increasingly used. It is now the technique of choice for most benign adrenal lesions because of the decreased blood loss, lower morbidity, shorter hospitalization, faster recovery, and overall cost-effectiveness in comparison with the open approach. [2, 3, 4, 5, 6, 7, 8, 9, 10, 11]
Because of the anatomic differences between right and left adrenal glands—most notably, different venous drainage patterns—surgical approaches are different for right and left adrenalectomy. It is essential that surgeons be cognizant of these differences.
Although laparoscopic right adrenalectomy is generally believed to be more difficult because of the proximity of dissection to the inferior vena cava (IVC) and duodenum and the short adrenal vein, one review comparing laparoscopic left and right adrenalectomies reported no differences in complication or conversion rates, with shorter operating times for the right. [12] One study found bleeding risk to be comparable for the two procedures (except with pheochromocytoma, metastasis, or masses >5 cm). [13] However, a 2022 systematic review and meta-analysis comparing the two found laparoscopic right adrenalectomy to be associated with a greater bleeding risk and a higher conversion rate. [14]
Indications
The indications for laparoscopic adrenalectomy have evolved since its initial description and subsequent wide adoption. Current indications are the same for laparoscopic adrenalectomy as for open surgery, except in cases of suspected or confirmed adrenocortical carcinoma.
Traditionally, open surgery was recommended for patients with suspected or known primary adrenal carcinoma because of the aggressive nature of the disease and the improved ability to perform an en-bloc resection. [15, 16] This recommendation came to be debated, with many reports at high-volume centers showing equal effectiveness of laparoscopic adrenal resection [17, 18, 19] and others continuing to recommend open surgery. [20, 21] The 2013 guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommended an open approach until more robust data could confirm the efficacy of laparoscopic adrenalectomy for adrenal carcinoma. [22]
A retrospective study of 201 patients who underwent either minimally invasive or open surgical adrenalectomy for adrenocortical carcinoma at 13 tertiary care cancer centers found that the minimally invasive approach was an acceptable alternative for tumors no larger than 10 cm. [23] However, the authors recommended that open adrenalectomy be performed in cases where there is preoperative or intraoperative evidence of local invasion or where enlarged lymph nodes are noted, regardless of size.
A commonly accepted indication for laparoscopic adrenalectomy is hormonally active tumors, including aldosteronomas, pheochromocytomas, and cortisol-producing adrenal tumors. Other indications involve size criteria and include nonfunctioning tumors less than 4-6 cm in diameter and smaller nonfunctioning tumors with rapid or progressive growth. Although no definitive size criteria for removal of nonfunctioning adrenal masses exist, it is well accepted that tumors larger than 6 cm should be removed because of an increased incidence of cancer with increasing size. [24]
Typically, nonfunctioning tumors smaller than 4 cm can be monitored with serial imaging; these are unlikely to be malignant. Patients with nonfunctioning tumors 4-6 cm in size should be presented with the options of serial imaging or laparoscopic adrenalectomy. The decision regarding treatment should be individualized. Some authors maintain that 6 cm need not be considered an upper size limit for transperitoneal laparoscopic adrenalectomy and that lesions larger than this can be safely and effectively treated with this procedure. [25, 26]
Patients with a solitary adrenal metastasis and no evidence of other metastatic disease are also candidates for laparoscopic adrenalectomy. [27, 28, 29]
Contraindications
A few absolute contraindications for laparoscopic adrenalectomy exist, including the following:
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Uncontrolled coagulopathy
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Severe cardiopulmonary disease
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Presence of a locally advanced tumor
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Medically untreated pheochromocytoma
Relative contraindications for the laparoscopic transperitoneal approach include patients who have had extensive previous abdominal surgery and pregnant patients. In patients with previous abdominal surgery, a laparoscopic retroperitoneal approach may be beneficial.
Technical Considerations
Anatomy
The adrenal glands, also known as suprarenal glands, belong to the endocrine system. (See Suprarenal (Adrenal) Gland Anatomy.) They are a pair of triangular-shaped glands, each about 5 cm (2 in.) long and 2.5 cm (1 in.) wide, that sit on top of the kidneys. The suprarenal glands are responsible for the release of hormones that regulate metabolism, immune system function, and the salt-water balance in the bloodstream; they also aid in the body’s response to stress.
Each suprarenal gland is composed of two distinct tissues: the suprarenal cortex and the suprarenal medulla. The suprarenal cortex serves as the outer layer of the suprarenal gland, and the suprarenal medulla serves as the inner layer. These two major regions are encapsulated by connective tissue known as the capsule.
Complication prevention
Hemorrhage from the adrenal vein or IVC is one of the most feared complications of a laparoscopic right adrenalectomy. If bleeding from the adrenal vein or IVC is suspected, direct pressure usually tamponades it. During this time, planning for permanent control either by a laparoscopic or open approach can be done.
Although many arterial branches supply the adrenal gland, most can be well controlled by using electrosurgical devices. When manipulating and removing the adrenal gland, caution must be used not to disrupt the capsule, as this can cause bleeding and potential spillage of malignant cells. Although bleeding from the adrenal gland itself usually is not hemodynamically significant, it often is a nuisance, disrupting visualization for the finer dissection and making it difficult to find the correct surgical planes.
In patients with functional tumors, consultation with an endocrinologist and an anesthesiologist is crucial for adequately preparing patients for surgery and avoiding intraoperative crises, most notably severe hypertension. Alpha blockade should be given to all patients with pheochromocytoma before surgery, followed by beta blockade only in patients with tachycardia.
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Port positioning for laparoscopic right adrenalectomy
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Port positioning for laparoscopic right adrenalectomy
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Mobilization of the liver with ultrasonic coagulation shears
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Laparoscopic right adrenalectomy: Liver retraction and dissection. Video courtesy of William W Hope, MD.
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Laparoscopic right adrenalectomy. Video courtesy of William W Hope, MD.
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Laparoscopic right adrenalectomy. Video courtesy of William W Hope, MD.
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Laparoscopic right adrenalectomy. Video courtesy of William W Hope, MD.
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Laparoscopic right adrenalectomy. Video courtesy of William W Hope, MD.
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Laparoscopic right adrenalectomy. Video courtesy of William W Hope, MD.
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Laparoscopic right adrenalectomy. Video courtesy of William W Hope, MD.
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Laparoscopic right adrenalectomy: Adrenal gland removal. Video courtesy of William W Hope, MD.
