Access the accompanying videos for this chapter online. Available on ExpertConsult.com .
The laparoscopic approach is ideal for patients with a well-circumscribed, benign-appearing lesion of the adrenal gland. Although neuroblastoma is the most common etiology for adrenal masses in children, these are usually identified late in the disease process and are seldom suitable for laparoscopic resection. However, a well-circumscribed neuroblastoma in the adrenal gland is certainly amenable to laparoscopic resection.
Most patients undergoing laparoscopic adrenalectomy are ready for discharge on either the first or second postoperative day. This technique is also ideal for the incidentally discovered lesion. Besides neuroblastoma, other lesions that can be managed using the laparoscopic approach include adenomas, pheochromocytomas, adrenal hyperplasias, localized adrenocortical carcinoma, and alveolar sarcomas.
Indications for Workup and Operation
The preoperative evaluation for an adrenal lesion is the same whether the mass is removed laparoscopically or with the open technique. In patients with incidentally discovered lesions, hormonal evaluation is required, including the dexamethasone suppression test and levels of aldosterone, cortisol, and adrenocorticotropic hormone, as well as evaluation for possible pheochromocytoma. Surgical removal is indicated for all functioning adrenocortical tumors and for pheochromocytoma. For incidentally discovered lesions, especially those larger than 3 to 4 cm, laparoscopic resection is also recommended. Lesions as large as 6.5 cm and maximum volumes of 145 mL have been successfully managed using the laparoscopic approach. For patients with pheochromocytoma, preoperative suppression is indicated for the laparoscopic procedure and for the open operation. These patients should receive α-adrenergic blockade before the operation to prevent the development of profound hypotension with removal of the catecholamine source.
Operative Technique
General endotracheal anesthesia is used for this operation. Positioning of the patient for right and left adrenalectomies is the same, but the operative steps are different. The patient is placed on the operating room table in a true lateral position with the kidney rest situated just cephalad to the iliac crest. The kidney rest is then raised, accentuating the space between the iliac crest and the 12th rib. Also, to further enlarge this space, the operating table is flexed ( Fig. 19-1 ). A urinary catheter is usually not needed. The abdomen and flank are prepped and draped sterilely. The umbilicus is not used for this operation, so the initial incision is 5 mm in length and is placed halfway between the umbilicus and the ipsilateral iliac crest. The Veress needle may be used, but the cutdown technique is preferred by some authors. With the cutdown technique, following the skin incision, the muscles of the anterior abdominal wall are divided using loupe magnification until the peritoneum is visualized and incised. A 5-mm blunt-tip cannula is gently inserted through the incision and into the abdominal cavity. Pneumoperitoneum is created to 15 mm Hg with a flow of 4 to 6 L/min. Diagnostic laparoscopy is performed with a 5-mm, 45-degree angled telescope introduced through this cannula. At this point, the accessory 5-mm ports are inserted under visualization.
Right Adrenalectomy
For a right adrenalectomy, the surgeon and camera holder stand at the patient’s back and the surgical assistant stands opposite the surgeon so that the surgeon is actually working in a lateral-to-medial direction. The patient is positioned in a left lateral decubitus position ( Fig. 19-2 ). After the initial 5-mm incision is created halfway between the umbilicus and the right iliac crest, a 5-mm cannula and an angled telescope are inserted. After insertion of the initial 5-mm cannula, a second port is positioned lateral to it, in the anterior axillary line. A third working port is then placed lateral to this 5-mm port. It is important to place these cannulas close to the 12th rib, so that the iliac crest does not limit manipulation of the instruments inserted through the ports. (One of these 5-mm ports is usually enlarged later to 10 mm for extraction of the specimen. Alternatively, a 10-mm port can be introduced now at one of these working sites and used for extraction of the specimen.) The fourth cannula is for the liver retractor and is introduced above and slightly medial to the first 5-mm port ( Fig. 19-3 ). The Nathanson liver retractor (Mediflex Surgical Products, Islandia, NY) is used to retract the right lobe of the liver once it has been mobilized. The Thompson self-retaining instrument holder (Thompson Surgical Instruments, Traverse City, MI) is secured to the liver retractor so that another assistant is not needed to hold it.
The surgeon works through the two lateral 5-mm ports with a grasping forceps in the left hand and the Harmonic Scalpel (Ethicon Endosurgery Inc., Cincinnati, OH) in the surgeon’s right hand. The first step is to incise the right triangular ligament of the liver so that the right lobe can be mobilized and retracted. This can be performed either with scissors connected to cautery or with the Harmonic Scalpel ( Fig. 19-4 ). Once the right lobe has been mobilized so that the right adrenal gland is visualized, the liver retractor is secured to the Thompson self-retaining bar and the right lobe retracted medially. The general idea is to incise the peritoneum that lies lateral, cephalad, caudal, and finally anterior to the right adrenal gland, as well as the surrounding retroperitoneal tissue, containing the arterial supply to the gland, with the ultrasonic scalpel, and then to ligate the vein as the last step. The Harmonic Scalpel is used to perform this lateral, cephalad, caudal, and anterior peritoneal and retroperitoneal dissection, which can usually be completed in 20 to 30 minutes ( Figs. 19-5 and 19-6 ). With lateral retraction of the adrenal gland, the vein can usually be visualized through the peritoneum overlying the medial portion of the gland. Dissection then proceeds in a caudal-to-cephalad direction toward the adrenal vein using the Harmonic Scalpel ( Fig. 19-7 ). There is occasionally an accessory vein, so it is important to watch for this possibility. Once the adrenal vein is visualized, it is doubly clipped on both the vena cava side and the adrenal gland side, and then divided between the middle clips ( Fig. 19-8 ). The rest of the dissection can be completed with the Harmonic Scalpel quite easily.
