34 Laparoscopic Lateral Transabdominal Adrenalectomy Sanziana Roman, Robert Udelsman

contents

34.1 Background . . . 325

34.2 Anatomic Considerations . . . 325 34.3 Indications for Laparoscopic

Adrenalectomy . . . 326

34.4 Technique of Laparoscopic Transabdominal Lateral Adrenalectomy . . . 326

34.4.1 Patient Positioning . . . 326

34.4.2 Laparoscopic Right Adrenalectomy . . . 328 34.4.3 Laparoscopic Left Adrenalectomy . . . 329 34.5 Complications . . . 331

34.5.1 Short-Term Complications . . . 331 34.5.2 Long-Term Complications . . . 331 34.6 Postoperative Care . . . 331

References . . . 331

34.1 Background

Early successful laparoscopic adrenalectomy was re- ported in 1992 by Gagner et al. [2, 3]. Since then, the efficacy, safety and advantages of this approach as compared to open techniques have been proven in several retrospective studies [4, 5, 7, 8]. Investiga- tors have shown decreased hospital stays, increased patient comfort and faster return to normal bowel function and physical activity. It is clear that laparo- scopic adrenalectomy can be performed safely in skilled hands for benign adrenal tumors less than 8–10 cm and small, isolated metastases to the adrenal gland. Most endocrine surgeons agree that malignant primary tumors of the adrenal gland are still con- sidered a contraindication for the laparoscopic ap- proach.

Various anatomical laparoscopic approaches have been performed, including lateral transabdominal, supine transabdominal, and retroperitoneal ap- proaches. The majority of surgeons have adopted the lateral transperitoneal approach for laparoscopic

adrenalectomy. This chapter reviews the principles of laparoscopic adrenal surgery, including anatomic considerations and the technical aspects for both right and left laparoscopic adrenalectomy.

34.2 Anatomic Considerations

The adrenal glands are retroperitoneal organs locat- ed along the superomedial aspect of both kidneys, embedded in Gerota’s fascia and surrounded by retroperitoneal fat. The glands have a fibrous capsule and a chromate yellow hue due to the high lipid con- tent of the cortex. The fibrous capsule should be kept intact throughout the dissection, thus avoiding cell spillage and possible implantation.

The adrenal glands weigh 4–7 g in the normal adult. The right adrenal gland is more pyramidal in shape, lying under the right hepatic triangular ligament, lateral and somewhat beneath the vena cava and superomedial to the right kidney. The left adrenal gland is more flattened, bounded superior- ly by the posterior omental bursa, stomach and the superior pole of the spleen, medially by the peri- aortic tissue, and inferiorly by the tail of the pan- creas and the splenic vessels. Both adrenal glands rest posteriorly on the respective crus of the dia- phragm.

They are highly vascular structures, deriving their arterial blood supply from a rich plexus of branches from the inferior phrenic arteries, aorta and renal ar- teries.Most commonly,they have a single central vein, but multiple veins can be found. The right adrenal vein is typically short, 0.3–1 cm long, draining direct- ly into the vena cava. The left adrenal vein is usually 2–3 cm long, draining from the inferomedial aspect of the adrenal gland into the superior aspect of the left renal vein. The inferior phrenic vein may join the left adrenal vein before its entry into the renal vein (Fig. 1).

34 Laparoscopic Lateral Transabdominal Adrenalectomy

Sanziana Roman, Robert Udelsman

34.3 Indications for Laparoscopic Adrenalectomy

Laparoscopic adrenalectomy is indicated for virtually all benign functional adrenal tumors as well as non- functional tumors that require extirpation due to tumor size,growth,or imaging characteristics.The indications for 100 consecutive laparoscopic adrenalectomies as re- ported by a single surgeon are seen in Fig. 2 [10].

34.4 Technique of Laparoscopic Trans- abdominal Lateral Adrenalectomy The technique for both right and left laparoscopic adrenalectomy follows the principles of open adrena-

lectomy. The dissection is carried out in an extracap- sular manner. Grasping the adrenal gland with la- paroscopic instruments should be minimized, if pos- sible, in order to avoid fracture of the gland, spillage of tumor cells and possible implantation. If the gland has been fractured significantly, the surgery may need to be converted to an open adrenalectomy. Grasping the periadrenal fat or gently pushing and elevating the gland results in adequate exposure. Control of the blood supply may be obtained by electrocoagulation, ultrasonic dissector, or endoscopic clips. The gland should be removed intact in an impermeable endo- scopic device, so that the specimen may be examined pathologically in its entirety.

34.4.1 Patient Positioning

A well-padded beanbag may used under the patient on the operating table. After general anesthesia is in- duced and all necessary monitoring is accomplished, a urinary drainage catheter and an orogastric tube are placed. It is essential that the stomach be decom- pressed, especially on the left side. The patient is placed in the lateral decubitus position, right side up for a right adrenalectomy, or left side up for a left adrenalectomy. The table is flexed, the patient’s lower leg is bent, while the upper leg is kept straight, Fig. 1. Normal adrenal anatomy

Fig. 2. Indications for surgery in 100 consecutive laparo-

scopic adrenalectomies [10]

and the kidney rest of the table is elevated. All pres- sure points must be carefully padded to prevent neurovascular injury.These maneuvers will maximize the space between the costal margin and the iliac crest (Fig. 3a). This positioning will also allow gravity retraction of adjacent organs and excellent expo- sure to the retroperitoneum. It will not permit access to the contralateral adrenal. For a concomitant bi-

lateral adrenalectomy, the patient will need to be repositioned at the conclusion of the first adrenalec- tomy.

The video monitors are positioned on each side of the patient’s head. The surgeon stands on the ventral side of the patient. The assistant and/or camera oper- ator can stay on the same side or opposite side of the surgeon, according to exposure necessity [1, 8].

34 Laparoscopic Lateral Transabdominal Adrenalectomy 327

10-12 mm port 5 mm port

5 mm port 10-12 mm port a

b

c

Fig. 3. a Patient positioning for lateral transabdominal laparoscopic adrenalectomy. b Port placement for right lateral trans-

abdominal laparoscopic adrenalectomy. c Port placement of left lateral transabdominal laparoscopic adrenalectomy

cytoma or chronic obstructive pulmonary disease, the pneumoperitoneum is poorly tolerated.In these cases, one can accomplish the operation laparoscopically us- ing decreased insufflation pressures. A 10 mm port is placed and a 30 degree side-viewing telescope is uti- lized to visualize the insertion of the remaining ports.

Two 5 mm ports are placed along the costal margin to- ward the flank. An additional port is placed medially to the first port for a liver retractor. This may be either a 5 mm or a 12 mm port, given the available liver re- tractors.A 5 mm 30 degree side-viewing telescope may also be available. This may be used in the 5 mm ports at various points in the case for optimization of visu- alization and angle of dissection.

liver is mobilized. The dissection is then carried out laterally and superiorly. Small arterial branches can be divided with the cautery or ultrasonic dissector.

The right adrenal vein is located usually medially and posteriorly, draining into the vena cava. Once the vein is gently dissected, it should be doubly clipped and transected (Fig. 5). Wide adrenal veins may need to be sequentially clipped or ligated.

Slipped clips or sutures from the proximal stump bleed briskly and control may be difficult. Undue traction on the adrenal vein may tear the vena cava.

Direct gentle caval compression may be attempted with an endoscopic Kittner dissector to minimize blood loss. If vascular control cannot be obtained en-

Fig 33-04

Triangular ligament

Liver

Kidney

Transverse colon

Fig. 4. Right laparoscopic adrenalectomy: mobilization of the triangular ligament of the liver

doscopically, the operation may need to be converted to an open procedure.

Accessory veins may be clipped or cauterized. The adrenal gland may extend beneath the vena cava.

Gentle blunt medial traction of the cava and lateral dissection of the gland releases the medial side of the adrenal.Inferiorly,the gland is dissected away from the superior pole of the kidney. The inferior adrenal pole may extend close to the renal vein.

The dissection is kept close to the adrenal capsule to avoid injury to hepatic veins superiorly, vena cava medially and the renal vein or accessory polar renal ar- teries inferiorly and posteriorly.

The gland is then extracted via an endoscopic pouch through one of the 10–12 mm port sites. If the tumor is large, the port site may need to be slightly en- larged.Morsellation of the gland is not recommended, as it compromises pathological examination.

34.4.3 Laparoscopic Left Adrenalectomy The patient is positioned in the left side up lateral de- cubitus position as described above. Three trocars are usually employed (Fig. 3c). Pneumoperitoneum is achieved through the first 10 mm port site located

along the left costal margin, lateral to the rectus mus- cle.An additional 5 mm port is placed superiorly along the costal margin and a third port, either 5 mm or 10 mm, is placed in the axillary line. Care should be taken in inserting this port as the splenic flexure of the colon may be adherent to the flank area. Occasionally, this will need to be mobilized prior to insertion of the third port. The 10 mm or 5 mm 30 degree telescope is employed via the flank port site, while the dissectors and grasper are used in the medial ports.

Using the grasper and either the coagulation scis- sors or the ultrasonic dissector, the colon is displaced inferiorly and the spleen is mobilized medially by in- cising the splenorenal ligament. An edge of ligament should be left on the spleen for grasping purposes,thus avoiding manipulation injury to the spleen. The dis- section of the ligament is carried up to the diaphragm to the level of the gastric cardia. This allows full medi- al rotation of the spleen and utilizes gravity for expo- sure. Great care should be exercised to avoid injury to either the diaphragm or the stomach, especially when using the ultrasonic dissector.

With the spleen retracted medially, the pancreatic tail is gently dissected off the retroperitoneum. The posteriorly located splenic vessels will be in view as the pancreas is mobilized medially.

34 Laparoscopic Lateral Transabdominal Adrenalectomy 329

Duodenum 1

Transverse colon Adrenal vein Inferior vena cava Liver

Gallbladder

Adrenal

Kidney

Fig. 5. Right adrenal vein clipping

should be clearly visualized and dissected prior to cautery. Utilizing the ultrasonic dissector is preferred to endoclips, thus avoiding clip clutter.

The lateral and superior aspect of the adrenal gland is then dissected free from retroperitoneal fat using the ultrasonic dissector. Inferiorly, the adrenal gland is gently dissected off the superior pole of the kidney.

The renal capsule should not be injured in order to avoid bleeding.

The adrenal vein is found in the inferomedial aspect of the gland draining in an oblique direction into the

Utilizing a 5 mm 30 degree angled telescope in various ports has the advantage of visualizing the ad- renal from different views,which may facilitate the dis- section.

Once the adrenal gland is free,it is removed in an en- doscopic pouch through the 10 mm port site. Hemo- stasis is assured by releasing some of the pneumoperi- toneal pressure in order to prevent small venous com- pressive effect. All port sites larger than 5 mm are closed in layers with fascial approximation and skin closure. A closed suction drain is rarely employed.

Fig. 33-06

Stomach Liver

Adrenal Kidney Spleen

Colon

Pancreas

Adrenal vein

Fig. 6. Left adrenal vein clipping

34.5 Complications

34.5.1 Short-Term Complications

Most complications of laparoscopic adrenalectomy are shared with the open techniques. Potential complica- tions from insertion of the Veress needle include bow- el perforation, liver injury and splenic injury. The liver may be injured with the liver retractor during a right adrenalectomy. Gentle retraction and adequate release of the right triangular ligament minimizes this risk.

Small capsular tears usually do not necessitate treat- ment, as they are self-limited. The spleen may also be injured by retraction with the grasper. Leaving a layer of the phrenolienal ligament on the splenic capsule af- fords a grasping area and avoids direct manipulation of the splenic capsule.Small capsular tears also tend to be self-limited. Good visualization of the operative field is important in dissection; therefore placing the patient in the lateral decubitus position and slight reverse Tren- delenburg will keep irrigation fluid and blood out of the operative field. Meticulous dissection in a clear op- erative field is key to avoiding significant bleeding from the adrenal veins, vena cava and the renal vein. Major hemorrhage should prompt open conversion.

Injury to the pancreas, colon or duodenum can be avoided by careful dissection and manipulation.

34.5.2 Long-Term Complications

Adrenal capsular tear and cell spillage has been re- ported, with subsequent implantation of tumor cells along the paracolic gutters and the retroperitoneum [6]. Adrenal cell spillage should be avoided by careful manipulation of the gland during dissection and re- moval.

In patients with Cushing’s syndrome positional skeletal fractures can be experienced. These patients may also develop pneumonias. Patients who undergo bilateral adrenalectomy and/or those with Cushing’s syndrome will develop adrenal insufficiency postop- eratively unless replaced with glucocorticoids.The ad- disonian crisis may present with abdominal pain,nau- sea, vomiting, fever, malaise, weakness and leukocyto- sis. Cardiovascular collapse with hypotension and shock may develop rapidly, if the crisis is not recog- nized and treated promptly with parenteral glucocor- ticoids.

Patients with pheochromocytoma may develop postoperative hypotension and rebound hyperin- sulinism.

Patients who undergo resection of an aldosterono- ma are at risk for postoperative mineralocorticoid in- sufficiency, manifested by hyperkalemia.

34.6 Postoperative Care

Patients who undergo unilateral or bilateral adre- nalectomy for Cushing’s syndrome should be given exogenous glucocorticoids and an appropriate taper should be scheduled. Once the patient can take oral medications, a maintenance dose of hydrocortisone or equivalent of 12–15 mg/m

is administered daily.

The steroid therapy should continue until nor- mal function of the hypothalamic-pituitary-adrenal axis has been achieved. Patients who undergo bi- lateral adrenalectomies also require mineralocorti- coid replacement with fludrocortisone acetate 100 µg per day [9].

Usually, patients will only necessitate parenteral narcotics for 24 h, and be switched to oral pain med- ication thereafter. Clear liquids may be started within 24 h and have diet advancement as tolerated. Most pa- tients will be discharged within 24–48 h postopera- tively with no physical restrictions. Most patients re- turn to work within 10–15 days.

Patients with pheochromocytoma should have uri- nary catecholamines measured within 6 months post- operatively and then annually.

References

1. Brunt ML (2000) Laparoscopic adrenalectomy, chap 34.

In: Eubanks WS, Swanstrom LL et al. (eds) Mastery of en- doscopic and laparoscopic surgery. Lippincott Williams and Wilkins, Philadelphia

2. Gagner M,Lacroix A,Bolte E (1992) Laparoscopic adrena- lectomy in Cushing’s syndrome and pheochromocytoma.

N Engl J Med 327:1033

3. Gagner M, Lacroix A, Prinz RA, Bolte E, Albala D, Potvin C, Hamet P, Kuchel O, Querin S, Pomp A (1993) Early ex- perience with laparoscopic approach for adrenalectomy.

Surgery 114:1120–4; discussion 1124–5

4. Linos DA, Stylopoulos N, Boukis M, Souvatzoglou A, Rap- tis S, Papadimitriou J (1997) Anterior, posterior, or la- paroscopic approach for the management of adrenal dis- eases? Am J Surg 173:120–5

5. Prinz RA (1995) A comparison of laparoscopic and open adrenalectomies. Arch Surg 130:489–494

6. Terachi T, Yoshida O, Matsuda T, et al. (2000) Complica- tions of laparoscopic and retroperitoneoscopic adrena- lectomies in 370 cases in Japan: a multi-institutional study. Biomed Pharmacother 54 Suppl 1:211s–214s

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