Laparoscopic Right Adrenalectomy Periprocedural Care

Updated: May 04, 2017
  • Author: William W Hope, MD; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Equipment

A standard laparoscopic tray, including laparoscopic graspers and scissors, is used for a laparoscopic right adrenalectomy. A laparoscopic right-angle dissector, laparoscopic Kittner, and hook electrocautery are often helpful in the dissection of the inferior vena cava (IVC) and adrenal vein. A laparoscopic suction/irrigator is often required to ensure adequate visualization during dissection and after gland removal to ensure hemostasis. 

Other instruments that may be employed, depending on individual preferences, include a liver retractor, specimen retrieval bag, and an electrosurgical instrument. The authors' preference for electrosurgical instruments include the Harmonic Scalpel (Ethicon Endo-Surgery, Inc, Cincinnati, OH) or LigaSure (Valleylab, Boulder, CO); however, other devices such as the Gyrus PKS Cutting Forceps (Gyrus ACMI, Maple Grove, MN) or EnSeal Tissue Sealing and Hemostasis System (SurgRx, Redwood City, CA) can be used, depending on the surgeon's preference.

A 10-mm clip applier is often used to ligate the adrenal vein, but in some cases, a vascular-load endoscopic stapling device may be necessary.

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Patient Preparation

Anesthesia

General anesthesia is required for laparoscopic adrenalectomy, with adjuncts for pain management (eg, an epidural or subcutaneous local anesthetic pain pump) left to the discretion of the surgeon and anesthesiologist. Constant communication with the anesthesiologist is essential in patients with hormonally or vasoactive tumors. Appropriate intraoperative monitoring includes an arterial line and urinary catheter. Careful preoperative management and control of the physiologic effects of hormonally or vasoactive tumors should involve an endocrinologist’s expertise.

Patients with pheochromocytoma should undergo alpha blockade at least 7-10 days before surgery. If tachycardia persists, then beta blockade should also be instituted after appropriate alpha blockade. Remember that beta blockade should not be used before alpha blockade is implemented, because of the potential for unopposed alpha stimulation, which could lead to marked hypertension.

In patients with hypercortisolism, stress doses of steroids should be administered before and after surgery. Again, a team concept involving anesthesia and endocrinology is crucial for optimal outcomes in patients with vasoactive tumors.

Before surgery, patients with aldosteronomas should have hypokalemia corrected, and blood pressure should be adequately controlled. Spironolactone, an aldosterone antagonist, is often given preoperatively to assist with blood pressure control.

A urinary catheter, an orogastric tube, and sequential compression devices are placed before positioning and turning. Appropriate antibiotics, usually a first-generation cephalosporin, are administered before incision. Most patients, with attention to appropriate selection, receive pharmacologic deep vein thrombosis prophylaxis.

Positioning

For a laparoscopic transperitoneal right adrenalectomy, the patient is placed in the left lateral decubitus or semilateral decubitus position, ranging from 45º to 70º. The authors prefer using a beanbag mattress, but a gel roll will suffice. The patient’s umbilicus should be near the joint in the table to allow for flexing of the table to improve flank exposure. Safety straps and tape are used to securely position the patient, and all pressure points should be padded to prevent nerve compression injuries.

The patient’s right arm is placed on an arm rest and should be adequately padded. A shoulder roll is also placed. Reverse Trendelenburg positioning can also help with exposure. The surgeon and assistant usually stand on the patient’s left side with the video monitors above the right and left sides of the bed; however, this can be individualized in accordance with the surgeon's preference.

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Monitoring & Follow-up

Long-term monitoring after laparoscopic adrenalectomy depends on the indication for surgery and the postoperative diagnosis. Patients who have had functional tumors removed are usually followed by an endocrinologist. In patients who have undergone removal of a pheochromocytoma, plasma fractionated metanephrines should be checked postoperatively and then annually.

In patients undergoing adrenalectomy for malignancy or metastasis, long-term follow-up should be coordinated with medical oncology.

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