Since the introduction of laparoscopic adrenalectomy in 1992, it has rapidly become the gold standard for surgical management of adrenal pathology. In this chapter, we describe current indications and techniques for laparoscopic adrenalectomy and discuss perioperative management and potential complications.
Indications and Contraindications
The indications for adrenalectomy are summarized in Box 40-1 . Adrenal masses 1 cm and larger require metabolic evaluation and imaging for appropriate classification, the details of which are beyond the scope of this chapter. Benign lesions can be either functional (metabolically active) or nonfunctional (inert). Metabolically active lesions should be removed in appropriate surgical candidates, with very careful attention to their perioperative management. Inert adenomas larger than 6 cm (some argue 4 cm) or with more than 1 cm of growth on follow-up imaging are to be considered malignant until proven otherwise and should be removed. Solitary metastatic lesions from a nonadrenal primary cancer (commonly lung, breast, kidney, and melanoma) can be removed laparoscopically, although the long-term benefits for the patient should be carefully considered.
Benign
Functional
Catecholamine
Mineralocorticoid
Aldosterone
Nonfunctional
Size >4-6 cm
Enlarging (>1 cm)
Malignant
Adrenal cortical carcinoma
Solitary lesion from nonadrenal primary
Relative contraindications to laparoscopic adrenalectomy include prior abdominal surgery, obesity, and tumor size. Extensive scarring and adhesions from prior abdominal surgery may increase the difficulty of a transperitoneal approach, but a retroperitoneal or transthoracic approach may be feasible. Similarly a flank approach may be more appropriate in obese patients. Body habitus may increase the technical difficulty, but the less invasive laparoscopic approach may be more beneficial for these patients because of their already compromised functional status. Currently, tumors up to 10 to 12 cm are generally considered resectable by experienced laparoscopic surgeons. However, patients must be carefully selected because tumors larger than 5 cm are significantly more likely to be malignant and are technically more difficult.
Resection of adrenal cortical carcinoma (ACC) should not be attempted laparoscopically if it will compromise cancer control. ACC is aggressive, with locoregional recurrence rates of more than 60%, and any degree of spillage or residual tumor may be harmful to the patient. These tumors are usually large and infiltrative, and the surgeon must be prepared for en bloc resection. ACC with evidence of extra-adrenal tumor invasion or adrenal vein thrombus extending into the inferior vena cava (IVC) is considered the only absolute contraindication to laparoscopic resection.
There are few indications for partial adrenalectomy. Patients with inherited disorders who have an increased propensity for recurrent adrenal lesions, such as multiple endocrine neoplasia (MEN) or von Hippel-Lindau (VHL) disease, are candidates for partial adrenalectomy. It may be considered for patients with a solitary adrenal gland as well.
Patient Preoperative Evaluation and Preparation
All patients should be counseled about standard surgical risks including infection, bleeding, damage to surrounding structures (spleen, liver, kidney, major vascular structures), and possible conversion to an open procedure, which occurs in 2% to 5% of cases. If ACC is suspected, patients should be counseled and should give informed consent for adjacent organ removal.
Specific considerations for pheochromocytoma include initiation of an α-blocker (typically phenoxybenzamine) at least 2 weeks before surgery and addition of a β-blocker if necessary. Give anesthesia advance notice, even for inert masses, because 5% of patients with pheochromocytomas have normal blood studies. Patients with glucocorticoid-producing tumors need adequate blood glucose control, and in some cases may benefit from adrenolytic agents such as mitotane, aminoglutethimide, or metyrapone. Perioperatively, hydrocortisone should be given. For aldosterone-secreting tumors, hypertension should be adequately controlled weeks before surgery and hypokalemia should be corrected, either by replacement or use of a potassium-sparing diuretic.
In the operating room, place sequential compression devices (SCDs) and a Foley catheter. For transperitoneal cases, a nasogastric or orogastric tube and preoperative bowel preparation may be helpful. Ensure that pressure points are properly padded, and administer perioperative antibiotics. If there is concern for rapid hemodynamic changes, close monitoring via an arterial line or pulmonary artery catheter may be warranted.
Operating Room Configuration and Patient Positioning
Transperitoneal Approach
Place the patient in a modified flank position, 20 to 30 degrees back from vertical, using a beanbag device or a padded roll if needed to keep the patient in position. The table should be flexed only during conversion to open surgery. Extend the lower arm on a standard arm board and place an axillary roll just caudad to the axilla. Bring the upper arm across the body and support it with a Krause (sling) rest, double arm board, or several pillows ( Fig. 40-1 ). To avoid undue strain on the upper shoulder joint, ensure the upper arm is adequately extended. Pad both arms under the elbows and wrists. SCDs should be placed on the calves. Then gently flex the legs and place a pillow between them and foam beneath the feet and ankles. Secure the patient to the table with wide tape strips across the hips and chest. Both surgeon and assistant stand on the patient’s ventral side ( Fig. 40-2 ) while the technician stands at the feet or on the dorsal side. Two monitors are positioned to ensure all members of the surgical team can view the procedure.
Retroperitoneal Approach
For the retroperitoneal approach, place the patient in full flank position ( Fig. 40-3 ). The flank should be positioned directly over the table break with the patient on a beanbag. Flex the table to adequately open the space between the 12th rib and the iliac crest. With the table flexed, adjust the bed to create a level operating surface (usually by raising the head). Arm extension and leg positioning are the same as for the transperitoneal approach. For the retroperitoneal approach, the surgeon and assistant stand on the patient’s dorsal side. Again, the configuration in the operating room allows for visualization of the procedure by the entire surgical team ( Fig. 40-4 ).
Operating Room Configuration and Patient Positioning
Transperitoneal Approach
Place the patient in a modified flank position, 20 to 30 degrees back from vertical, using a beanbag device or a padded roll if needed to keep the patient in position. The table should be flexed only during conversion to open surgery. Extend the lower arm on a standard arm board and place an axillary roll just caudad to the axilla. Bring the upper arm across the body and support it with a Krause (sling) rest, double arm board, or several pillows ( Fig. 40-1 ). To avoid undue strain on the upper shoulder joint, ensure the upper arm is adequately extended. Pad both arms under the elbows and wrists. SCDs should be placed on the calves. Then gently flex the legs and place a pillow between them and foam beneath the feet and ankles. Secure the patient to the table with wide tape strips across the hips and chest. Both surgeon and assistant stand on the patient’s ventral side ( Fig. 40-2 ) while the technician stands at the feet or on the dorsal side. Two monitors are positioned to ensure all members of the surgical team can view the procedure.
Retroperitoneal Approach
For the retroperitoneal approach, place the patient in full flank position ( Fig. 40-3 ). The flank should be positioned directly over the table break with the patient on a beanbag. Flex the table to adequately open the space between the 12th rib and the iliac crest. With the table flexed, adjust the bed to create a level operating surface (usually by raising the head). Arm extension and leg positioning are the same as for the transperitoneal approach. For the retroperitoneal approach, the surgeon and assistant stand on the patient’s dorsal side. Again, the configuration in the operating room allows for visualization of the procedure by the entire surgical team ( Fig. 40-4 ).
Trocar Placement
Transperitoneal Approach
Left-Sided Adrenalectomy
A left-sided adrenalectomy requires three ports along the costal margin with an optional fourth port if additional retraction is needed. The primary site is a 10-mm port two fingerbreadths below the costal margin in the midclavicular line. Note that in the lateral position, most patients have a slight hollow at this site. Two 5-mm secondary ports are placed just below the costal margin. The first is placed medially and cephalad, just lateral to the rectus abdominis muscle, and is used primarily for retraction and irrigation-aspiration. The second 5-mm port is placed lateral and caudad to the primary site to accommodate scissors, dissectors, and a clip applier ( Fig. 40-5 ). Finally, if difficult anatomy or dissection requires the use of a fourth port, place it laterally. Some flexibility in port use allows exposure of the adrenal to be optimized by shifting the laparoscope according to anatomy and body habitus. This setup is considered a lateral transperitoneal approach.
Right-Sided Adrenalectomy
A right-sided transperitoneal adrenalectomy always requires four ports to allow for continuous liver retraction during the procedure. As with the left side, place the primary 10-mm port in the midclavicular line. Access this site in a caudad direction to avoid injuring the liver on initial entry. Subsequent 5-mm ports should be placed along the costal margin as shown in Figure 40-6 . Alternate between these ports as needed to access the short adrenal vein during the procedure.
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