Laparoscopic Right Adrenalectomy Technique

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

Approach Considerations

Three different surgical approaches have been described for laparoscopic adrenalectomy, as follows:

  • Transabdominal lateral flank approach
  • Anterior transabdominal approach
  • Retroperitoneal approach [25, 26]

Although each technique has its merits and proponents, the transabdominal lateral flank approach is the one that currently is most often used; it is the focus of the following discussion.

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Transabdominal Lateral Flank Approach

Port positioning and laparoscopic access

Laparoscopic access may be obtained via an open or a closed technique, depending on the surgeon's preference and expertise. The authors' preference is to place a Veress needle just below the costal margin and preinsufflate the abdominal cavity. This is followed by optical trocar entry with a 5-mm trocar at the midclavicular line, approximately two fingerbreadths below the costal margin. This 5-mm trocar can be later "upsized" to an 11-mm trocar.

An alternative is an open cutdown at this area; however, the incision needed for this usually requires the placement of a 10- to 12-mm trocar or balloon-type trocar to prevent leakage of pneumoperitoneum. Four laparoscopic ports placed in the right subcostal region are typically required for laparoscopic right adrenalectomy, though some reports have described the use of single-incision techniques (including robotic-assisted approaches). [27, 28, 29, 30, 31]

Port positioning and size of ports vary and are surgeon-dependent. However, at least one 11- to 12-mm port is required to accommodate a clip applier or an endoscopic stapler. The remaining ports may be 5 mm. Our typical port placement involves a 10- to 12-mm trocar placed in the subcostal region at the anterior axillary line (camera port), a 10- to 12-mm trocar in the subcostal region at the midclavicular line (surgeon’s right-hand working port), a 5-mm trocar in the subcostal region just to the right of the umbilicus (liver retraction), and a 5-mm trocar in the posterior axillary line subcostally (surgeon’s left-hand working port). (See the images below.)

Port positioning for laparoscopic right adrenalect Port positioning for laparoscopic right adrenalectomy
Port positioning for laparoscopic right adrenalect Port positioning for laparoscopic right adrenalectomy

Alternatively, the surgeon can use the two "inside" ports for working ports and have the camera coming in from the port in the posterior axillary line.

Liver retraction and dissection

After safe laparoscopic access and port placement, diagnostic laparoscopy is performed to rule out other pathologic or anatomic abnormalities. At this time, attention is focused to the right upper quadrant as the liver is retracted from the port just lateral to the xiphoid. Liver retraction may be performed with a blunt grasper, a fan retractor, kite or snake-type retractors, or a Nathanson liver retractor. The liver is mobilized anteriorly and medially by incising the retroperitoneal attachments medially and then the triangular ligament to the level of the diaphragm (see the image and video below.)

Mobilization of the liver with ultrasonic coagulat Mobilization of the liver with ultrasonic coagulation shears
Laparoscopic right adrenalectomy: Liver retraction and dissection. Video courtesy of William W Hope, MD.

Adequately mobilizing the liver by means of continued cephalad retraction with the liver retractor is crucial because the adrenal gland and vein are usually more cephalad than most surgeons appreciate. Mobilizing the hepatic flexure of the colon is usually not necessary; however, if the hepatic flexure is obscuring the view or if injury during instrument exchange is a concern, it can be mobilized inferiorly and medially with sharp dissection. The amount of dissection of the ascending colon and hepatic flexure varies, depending on the anatomy of the patient and the size of the adrenal tumor.

At this time, if the adrenal is not visualized, it is often helpful to start the dissection on the inferior vena cava (IVC), which can be a good landmark during the case (see the video below).

Laparoscopic right adrenalectomy. Video courtesy of William W Hope, MD.

The dissection of the IVC should start just above the renal vessels, which are often visible and then move cephalad. Intraoperative laparoscopic ultrasonography may also be helpful for identifying a hard-to-locate gland or evaluating the venous anatomy. Dissection of the IVC can be performed sharply with laparoscopic shears or with a hook electrocautery.

The surgeon must appreciate that the duodenum is in close proximity during this dissection and may be mobilized medially to procide better visualization if needed or to ensure that no iatrogenic injuries occur during dissection. Again, if the adrenal vein or gland is difficult to find, it is usually more cephalad, and further mobilization and retraction of the liver is needed.

When the IVC is visible, the dissection progresses superiorly toward the liver. If the peritoneum on the inferior border of the liver was not previously divided, then further dissection is needed and is started at the IVC and carried out laterally (see the video below).

Laparoscopic right adrenalectomy. Video courtesy of William W Hope, MD.

At this time, the liver retractor can be replaced to allow more upward retraction and a better view of the adrenal gland. Next, the adrenal vein should be visualized and carefully dissected (see video below).

Laparoscopic right adrenalectomy. Video courtesy of William W Hope, MD.

Adrenal vein dissection and ligation

Extreme caution should be used in dissecting out the right adrenal vein; it is often short and broad, and hemorrhage resulting from injury in this area can be very difficult to control. The authors' practice is to use a right-angle dissector or Maryland dissector to gently dissect the vessel at the junction of the IVC (see the video below).

Laparoscopic right adrenalectomy. Video courtesy of William W Hope, MD.

After the junction of the adrenal vein and the IVC has been dissected, a 10-mm "safety clip" can be placed at this junction. This allows further dissection of the vein and ensures that potential injury to the vein will be easier to control. After the vein is adequately dissected, two or three 10-mm clips are placed on the proximal side (toward the IVC), and one or two are placed on the distal side (see the video below).

Laparoscopic right adrenalectomy. Video courtesy of William W Hope, MD.

Again, the adrenal vein is usually quite short, and thus accurate clip placement is vital; sometimes the distal clip is placed onto the adrenal gland. After the adrenal vein is adequately clipped, it is transected with scissors between the clips. Alternatively, if the adrenal vein is long enough and the dissection is adequate, an endoscopic stapler may be used to ligate the adrenal vein, though this can be challenging, given the anatomy and the location of the targeted adrenal vein.

Although still investigational, a series of laparoscopic adrenalectomies without the use of clips or sutures for hemostasis was reported. [32]  In this series, 32 patients underwent laparoscopic adrenalectomy with the LigaSure device for hemostasis and dissection, though the authors did not specifically isolate the adrenal vein. There was minimal blood loss and no major bleeding complications .

Adrenal gland dissection

After the adrenal gland is controlled and divided, the remainder of the operation focuses on the dissection of the adrenal gland away from its remaining attachments. Great care must be taken not to disrupt or damage the adrenal capsule, especially in the setting of a pheochromocytoma or malignant neoplasm. Avoid grasping the adrenal gland. Instead, the periadrenal fat or overlying peritoneum can be grasped, or the gland can be bluntly retracted. Although numerous small arterial branches supply the adrenal gland, these are usually well controlled by using an electrosurgical device. If a larger vessel is encountered, clips can be used as well (see the video below).

Laparoscopic right adrenalectomy: Adrenal gland removal. Video courtesy of William W Hope, MD.

Adrenal gland removal and closure

After the adrenal gland has been completely dissected from its attachments and is free, it is placed in a specimen retrieval bag and removed through a 10-mm trocar. Depending on the size of the gland/tumor, the incision may have to be enlarged. Following gland removal, the adrenal bed is inspected for hemostasis, with the pneumoperitoneum pressure decreased to 6-8 mm Hg.

The adrenal vein clips/staples are inspected to ensure adequate ligation, and the area is irrigated and aspirated. Careful inspection of the area of dissection and surrounding areas is performed to identify inadvertent injuries. The 10-mm ports can then be closed, either laparoscopically with a suture passer or in an open fashion with an absorbable or permanent suture. The 5-mm trocars are removed under direct vision to ensure hemostasis, and the abdomen is desufflated. The port sites are closed with an absorbable suture, and surgical glue or dressings is applied.

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Postoperative Care

Postoperatively, patients are usually transferred to a regular surgical floor unless there are concerns about hemodynamic issues, cardiopulmonary status, or intraoperative complications. Currently, laparoscopic right adrenalectomy is an inpatient procedure; however, some reports have detailed performing this operation as an outpatient procedure on a small number of patients in specialized units. [33, 34]

A clear liquid diet can be started when the patient is awake and alert, and diet can be advanced as tolerated. Pain control is initiated with intravenous narcotics is begun but often can be rapidly transitioned to oral analgesics because of the limited amount of pain experienced by the patient. A complete blood count is obtained on postoperative day 1 with electrolyte monitoring as clinically indicated. Patients are usually discharged 24-48 hours after surgery.

Routine office follow-up is typically done 2-3 weeks after discharge, depending on the surgeon's preference, and wound complications are rarely encountered. In patients with Cushing syndrome, postoperative steroid management is usually coordinated in consultation with endocrinology.

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Complications

The most serious and feared complication of a laparoscopic right adrenalectomy is hemorrhage from the adrenal vein or the IVC, which can cause severe blood loss and may necessitate conversion to an open procedure. Control of the bleeding with direct pressure can often minimize the bleeding and, depending on the injury, may be handled laparoscopically by means of suturing or the use of hemostatic agents. If the injury is more complex, direct pressure may be placed while an open incision is made.

Other intraoperative complications are similar to those seen with  other laparoscopic procedures and include injuries adjacent to structures such as the colon, small bowel and duodenum, liver, gallbladder, and diaphragm. [35]

Additional complications encountered during laparoscopic adrenalectomy include those related to hormonally active tumors, most notably pheochromocytoma. Failure to adequately prepare patients with pheochromocytoma preoperatively can result in severe hypertensive crisis intraoperatively. Adrenal insufficiency may occur in patients with hypercortisolism who do not receive appropriate stress-dose steroids.

One large registry found that surgeon inexperience, greater patient age, higher body mass index (BMI), larger tumor size, and the presence of pheochromocytoma are risk factors for complications associated with laparoscopic adrenalectomy. If the surgeon is at an early point along the learning curve, these factors should be taken into account in deciding on operative planning. [36]

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