INTRODUCTION

There are few operations better served by laparoscopy than adrenalectomy. The pathologic adrenal gland is usually small (between 3 to 6cm. ) It is located in the upper retroperitoneum superior and posterior to the respective kidneys. Both glands are closely related to major vascular structures. Laparoscopy provides a well illuminated, detailed view of the entire gland, whereby deliberate sharp dissection completes removal. Vasculature that is unappreciated in the open case is visualized and addressed. This approach has the obvious advantages of smaller incisions and shorter recovery periods. In addition laparoscopic adrenalectomy is associated with less blood loss and shorter operative times. The chapter that follows describes the authors' technical experience with and recommendations for laparoscopic adrenalectomy. Although most adrenal glands can be removed with laparoscopic technique, expertise with and preparation for the open case is a prerequisite. We favor the anterior, transabdominal approach, opposed to the retroperitoneal, or flank technique. The working space of the abdomen is larger, conversion to the open procedure is expeditious, and the transabdominal route is more successful for large tumors.

The right side is described first, followed by a description of the left. The wheel is not reinvented to describe left adrenalectomy . Instead, the left is addressed in contrast to the right. If you are only interested in the left side, then the right side is prerequisite reading.

1. Production of excess adrenal hormones

A. Cortisol from a cortical adenoma (Cushing's syndrome)

B. Aldosterone from a cortical adenoma (Conn's syndrome)

C. Sex hormones from cortical adenoma (virulization)

D. Catecholamines (pheochromocytoma)

 

2. Non functioning cortical adenoma if:

A. greater than 4-6cm.

B. or demonstrates growth over 1 to 2 year period.

1. Extra adrenal tumor by CT, MR or MIGB.

2. Evidence of, or suspicion for malignancy.

3. Unstable patient, bleeding disorders, unprepared surgeon or facility(absolute)

 

1. Right angle dissector

2. Bag retrieval device.

3. Liver retractor

4. Optional: Ultrasonic dissecting device

Room Setup

The surgeon stands on the right side of the table,

with the assistant across from him/her.

Each has their own monitor.

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Illustrations

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PITFALLS

1.)Trocar Placement: The described port placement should not be considered "fixed in stone". While the described arrangement depends on ideal anatomy, variation is the norm. The principal of a semicircle with a 12 to 15 cm radius around the target tissue is a good guideline. In smaller individuals this may mean the ports extend to the left of the midline in order to maintain distance between each port and their distance from the adrenal gland.

2.)CO2 Embolus: Caval CO2 embolus causes a rapid cardiovascular collapse, a precordial "wheel mill" murmur, and a precipitous drop in end tidal CO2. Treatment is: 1.) Prompt release of the pneumoperitoneum. 2.)Trendelenburg positioning 3.) Cardiac massage if needed. Aspiration of air via a central venous line has been described for this situation. Carbon dioxide is readily absorbable and resuscitation is often successful despite a large embolus, and ominous physiologic signs.

3.)Large Tumors: There has been limited success with removing larger adrenal tumors. Our experience reflects that of other authors who have had difficulty with glands larger than 6 cm, particularly on the right.

4.)Pheochromocytoma: The tradition of addressing the major vascular structures first is avoided in the laparoscopic approach. Lateral and posterior dissection is a prerequisite to the lateral retraction necessary to address the large medial vessels. In theory less manipulation of the tumor is required in the laparoscopic approach and in our experience the hemodynamic course has been at least equivalent to that of the open (hands on) approach. The laparoscopic approach does not alter the need for alpha, and when indicated, beta blockade as generally described for the treatment of pheochromocytoma.

 

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REFERENCES

Fernandez-Cruz L., Saenz A., Benarroch G., et al. Laparoscopic unilateral and bilateral adrenalectomy for Cushing's syndrome. Transperitoneal and retroperitoneal approaches. Annals of Surgery. 224(6):727-34, Dec., 1996.

Duh QY., Siperstein AE., Clark OH., et al. Laparoscopic adrenalectomy. Comparison of lateral and posterior approaches. Archives of Surgery. 131(8)870-5, Aug., 1996.

Brunt LM., Doherty GM., Norton JA., et al. Laparoscopic adrenalectomy compared to open adrenalectomy for benign adrenal neoplasms. Journal of the American College of Surgeons. 183(1):1-10, Jul. 1996.

Staren ED., Prinz RA. Adrenalectomy in the era of laparoscopy. Surgery. 120(4):706-9, Oct., 1996.

Gagner M. Laparoscopic adrenalectomy. Surgical Clinics of North America. 76(3):523-37, Jun., 1996.

Marescaux J., Mutter D., Wheeler MH.. Laparoscopic right and left adrenalectomies. Surgical procedures. Surgical Endoscopy. 10(9):912-5, Sep., 1996.

Rutherford JC., Stowasser M., Tunny TJ., et al. Laparoscopic adrenalectomy. World Journal of Surgery. 20(7):758-60, Sep., 1996.

Petelin JB. Laparoscopic adrenalectomy. Seminars in Laparoscopic Surgery. 3(2):84-95, Jun.,1996.