Laparoscopic Adrenalectomy

Sanziana A. Roman, MD
Student Author:
Brian Burbidge , Kaya Garringer , Calder Dorn, Matthew Zeller

Background Information: Adrenalectomy is the removal of the adrenal gland. This procedure may be performed transabdominally, retroperitoneally, or transthoracically, via an open procedure or minimally invasive approach (laparoscopically or robotically). 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 preferred1. 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 recoveries1. For patients with previous abdominal surgery or patients that require bilateral adrenalectomies, the posterior retroperitoneoscopic approach is preferred. The approach avoids previous surgical sites and does not require repositioning for bilateral procedures. Retroperitoneal views lack access to the abdominal cavity for evaluation.


Indications: The indications for adrenalectomy include an array of clinical diagnoses. In general, surgery is indicated for non-malignant tumors that are functioning such as aldosteronoma or Cushing syndrome.4 If non-functioning, surgical treatment is considered if tumors are 3-5cm and indicated if >5cm. 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. If metastatic, treatment is commonly non-surgical with the chemotherapeutic agent mitotane.
  • 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 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 the 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


Anatomy

Right Adrenal

Left Adrenal

Adrenal Gland (suprarenal)

Posterolateral to the abdominal inferior vena cava (IVC), superomedial to the right kidney, anterior the diaphragm, and posteroinferiorly to the liver

Medial to the kidney, lateral to the abdominal aorta, anterior to the diaphragm, and posterior to the tail of the pancreas and splenic hilum

Adrenal Arteries

Diffuse arterial supply directly from the aorta (medially), the inferior phrenic artery (superiorly), and the right renal artery (inferiorly)

Same as right

Adrenal Vein

Singular drainage to IVC (medially)*. Often much shorter than left.

Singular drainage to the left renal vein (inferiorly) after joining with inferior phrenic vein 

Table 1. Anatomical differences based on laterality of adrenal gland2. *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%3)
  • Damage to surrounding organs (kidney, spleen, pancreas, liver, blood vessels) (2.9–20%4)
  • Port site Infection (5%2)
  • Subcostal Nerve damage (8%2)


Key Literature:

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


Additional resources:

ACS Medical Student Curriculum - Endocrine Disease


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
  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. Townsend CM, Sabiston DC. Sabiston Textbook of Surgery E-Book [Internet]. Vol. 19th ed. Philadelphia, PA: Saunders; 2012.
  3. 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
  4. Assalia, A, and M Gagner. “Laparoscopic adrenalectomy.” The British journal of surgery vol. 91,10 (2004): 1259-74. doi:10.1002/bjs.4738
  5. https://www.nccn.org/professionals/physician_gls/pdf/neuroendocrine.pdf (Accessed on December 17, 2020