Surgical Procedures

Laparoscopic Adrenalectomy

As you know, a laparoscopic adrenalectomy allows surgeons to safely remove a diseased adrenal gland, but while it is easier for the patients, it’s not easy for you – the procedure itself is technically demanding, with only minimal incisions. Professor Sanziana performs a posterior retroperitoneoscopic adrenalectomy for you to read and watch, as she removes the left adrenal metastatic melanoma in a 66-year-old woman.
General Surgery
Sanziana A. Roman, MD, FACS, UCSF


Background Information: ‍

Adrenalectomy is the removal of the adrenal gland. This procedure may be performed transabdominally, retroperitoneally, or transthoracically via an open or minimally invasive approach (laparoscopic or robotic). The choice of an open or laparoscopic approach is decided on a case-to-case basis. In cases of large tumors (>6cm), metastasis, and invasion of the tumor into surrounding structures, an open approach is preferredⁱ. The lateral transabdominal adrenalectomy is the most common technique. The lateral positioning pulls the abdominal contents out of the surgical field and provides a larger working space for the surgeon. The gold standard for patients not indicated for an open procedure is the lateral laparoscopic transabdominal adrenalectomy. This technique provides the same benefits as the open procedure, with the added benefits of smaller incisions, shorter hospital stays, and earlier recoveriesⁱ. For patients with previous abdominal surgery or patients that require bilateral adrenalectomies, the posterior retroperitoneoscopic approach is preferred. This approach avoids likely adhesive abdominal disease and does not require repositioning for bilateral procedures. The retropertional approach lacks access to the abdominal cavity for evaluation or control of complications.


Indications:

‍The indications for adrenalectomy include an array of clinical diagnoses. In general, surgery is indicated for non-malignant functioning tumors such as aldosteronoma or Cushing syndrome.² If non-functioning, surgical treatment is considered for 3-5 cm tumors and indicated if >5 cm. Malignant tumors are resectable unless they are metastatic primary adrenal cancers but may require en bloc resection of neighboring organs if the tumor is locally invasive. Possible indications for adrenalectomy include: 


  • Adrenocortical carcinoma (ACC) if not metastatic. 
  • Pheochromocytoma
  • Hormonally active tumors 
  • Aldosteronoma 
  • Cortisol producing adenoma also known as primary adrenal Cushing syndrome 
  • Adrenal metastasis
  • Symptomatic Angiomyolipomas
  • Bilateral adrenal hyperplasia following failed pituitary surgery for Cushing’s disease
  • Adrenal Incidentaloma



Procedure Description: 

The most common approach is the laparoscopic lateral transabdominal adrenalectomy. The patient is placed in the lateral decubitus position with the side of the lesion facing upwards. An important step of the transabdominal left adrenalectomy is the open book technique where the spleen and tail of pancreas are reflected medially and comprise the right “page”, the kidney and adrenal gland comprise the left “page”, and the cleft of the book is where the inferior phrenic vein and medial border of the adrenal gland are located. It is essential to avoid tearing the splenic capsule or damaging vessels in the spleen or tail of the pancreas. Once the adrenal gland is visualized, the adrenal arteries followed by the adrenal vein, are handled with coagulation or clipping. Care must be taken when dissecting the inferior margin of the adrenal gland as many patients may have a superior pole renal artery branch in that region. 


The last attachments dissected are the posterior attachment to ensure that the adrenal gland does not fall into the surgical field during the procedure. The approach of the right adrenal gland mimics the approach of the left very closely. To gain access, the right triangular ligament of the liver must be mobilized to fully expose the surgical space. For the open transabdominal approach, an incision is made subcostally and similar steps are followed as the laparoscopic approach. Ligations of the veins and arteries are completed the same way in all the approaches.


The posterior retroperitoneoscopic approach, as seen in the video, avoids mobilization of the abdominal and retroperitoneal organs but decreases the size of the surgical space. The patient is prone with the knees flexed, and the retroperitoneal contents are bluntly dissected anteriorly away from the entry point. The paraspinal muscle is used as the main landmark and marks the point of the beginning of the mobilization of the adrenal gland.



Key Anatomy:

  • Kidney
  • Renal Hilum
  • Gerota’s Fascia
  • Renal Artery/Vein
  • Psoas Muscle
  • Inferior Phrenic Artery/Vein
  • Spleen
Table 1. Anatomical differences based on laterality of adrenal gland³. *anatomical variations may occur resulting in the left adrenal vein draining to the right renal vein confluence, higher on the IVC, or at the hepatic vein confluence.


Surgical Risks:

  • General surgical risks:
  • Bleeding
  • Infection
  • Risks specific to adrenalectomy: 
  • Adrenal Insufficiency (5-20%⁴)
  • Damage to surrounding organs (kidney, spleen, pancreas, liver, blood vessels) (2.9–20%²)
  • Port site Infection (5%³)
  • Subcostal Nerve damage (8%³)



Key Literature:

NCCN Guidelines - https://www.nccn.org/professionals/physician_gls/pdf/neuroendocrine.pdf


Additional resources:

  • Osmosis:


Online MedEd:


Text:

  • Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice by Courtney M. Townsend Jr. JR. MD
  • Zollinger's Atlas of Surgical Operations, Tenth Edition 10th Edition by Robert Zollinger, E. Ellison 
  • Atlas of General Surgical Techniques: Townsend, Evers
  • Essentials of General Surgery 5th Edition, by Peter F. Lawrence MD, Richard M. Bell MD, Merril T. Dayton MD, James C. Hebert MD FACS


References:

  1. Stefanidis, Dimitrios et al. “SAGES guidelines for minimally invasive treatment of adrenal pathology.” Surgical endoscopy vol. 27,11 (2013): 3960-80. doi:10.1007/s00464-013-3169-z
  2. Assalia, A, and M Gagner. “Laparoscopic adrenalectomy.” The British journal of surgery vol. 91,10 (2004): 1259-74. doi:10.1002/bjs.4738
  3. Townsend CM, Sabiston DC. Sabiston Textbook of Surgery E-Book [Internet]. Vol. 19th ed. Philadelphia, PA: Saunders; 2012.
  4. Mitchell, Jamie et al. “Unrecognized adrenal insufficiency in patients undergoing laparoscopic adrenalectomy.” Surgical endoscopy vol. 23,2 (2009): 248-54. doi:10.1007/s00464-008-0189-1

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