Adrenalectomy
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Adrenalectomy is the surgical removal of one or both (bilateral adrenalectomy) adrenal glands. It is usually advised for patients with tumors of the adrenal glands. The procedure can be performed using an open incision or laparoscopic technique.
Choice of procedure
Adrenalectomy may be preformed via open or laparoscopic technique. In either approach, the gland may be approached anteriorly, laterally or posteriorly via retroperitoneum. Laparoscopic adrenalectomy has rapidly become the standard procedure of choice for excision of most benign-appearing adrenal lesions less than 6 cm in diameter, but its role in management of adrenocortical cancers is controversial. Open technique is the safest option when dealing with suspected or known adrenocortical cancer and malignant pheochromocytoma.
Open adrenalectomy
Of the four approaches to open adrenalectomy (transabdominal, flank, posterior retroperitoneal and thoracoabdominal approaches), the anterior transabdominal approach is the preferred method for any tumors that are too large to be removed laparoscopically and for all invasive adrenal malignancies. The incision most commonly used is an extended unilateral or bilateral subcostal incision, though a midline incision is also an option. The extended subcostal incision yields exposure of both adrenal glands, as well as the rest of the peritoneal cavity. If necessary, it may be extended superiorly in the midline to the xiphoid to provide better upper abdominal exposure for full mobilization of the liver and access to the hepatic veins and the vena cava. The exposure obtained with this incision is sufficient for all but the most extensive adrenal malignancies. If the tumor involves the vena cava, the incision may be extended into a median sternotomy to provide access to the superior vena cava and the heart. The classic thoracoabdominal incision, which extends from the abdomen up through the seventh or eighth intercostal space and through the diaphragm, provides excellent exposure but is associated with increased incision-related morbidity and is rarely used.
Much of the exposure and dissection is the same as in a laparoscopic adrenalectomy; however, because open adrenalectomy is often employed for removal of particularly large tumors, some additional maneuvers may be necessary to achieve adequate exposure and vascular control. For example, it may be helpful to elevate the flank with a roll or a bean-bag mattress and then flex the operating table to open up the space between the costal margin and the iliac crest. Once the abdomen is entered, exploration is carried out for the presence of metastatic disease. Exposure of the adrenal on the right side is achieved by dividing the right triangular ligament of the liver, as in the laparoscopic approach. The hepatic flexure of the colon is also reflected inferiorly. With large tumors, a Kocher maneuver should be performed to afford better exposure of the vena cava and the renal vessels. The remainder of the dissection proceeds in much the same manner as in a laparoscopic right adrenalectomy. For suspected adrenal malignancies, a wide resection should be carried out, with removal of periadrenal fat and lymphatic tissue and any suspicious lymph nodes. For tumors that appear to involve the vena cava, vascular control of both the IVC proximal and distal to the tumor and the renal veins should be achieved before the lesion is removed.
Open left adrenalectomy entails mobilization of the splenic flexure of the colon and division of the splenorenal ligament. The spleen, the tail of pancreas, and the stomach are reflected medially en bloc to expose the left kidney and the left adrenal. The left adrenal vein is ligated with clips or silk ties near its junction with the renal vein. The remainder of the dissection proceeds as in a laparoscopic left adrenalectomy. For left-side primary adrenal malignancies, periaortic lymphatic vessels and lymph nodes should be removed along with the specimen. If a large left-side tumor is invading adjacent structures, removal may require en bloc resection of the spleen, the distal pancreas, and the kidney.
Laparoscopic adrenalectomy
When compared with open adrenalectomy, laparoscopic adrenalectomy has been shown to result in decreased requirement for postoperative pain medication, shorter postoperative ileus, more cosmetically acceptable scars, faster rehabilitation, and lower hospital costs. Laparoscopic adrenalectomy is most suitable for small adrenal masses in an otherwise normal gland. It is the procedure of choice for patients with aldosteronomas, small cortisol-producing adenomas, and small hereditary pheochromocytomas. Expertise in open adrenalectomy is absolutely necessary for the laparoscopic surgeon to convert to an open procedure and to rectify any intraoperative laparoscopic complications promptly. Adrenalectomy for a nonfamilial pheochromocytoma requires exploration of the entire abdomen, best conducted by direct palpation and visualization. Similarly, excision of large malignant tumors with potential invasion of nearby structures can be safely accomplished only by open adrenalectomy.
Laparoscopic adrenalectomy is performed with the patient in the lateral decubitus position with the table flexed at the space between the costal margin and the anterior superior iliac spine. The patient's arm is suspended, and care is taken to prevent compression of the shoulder facing downward. The surgeon and the assistant stand at the patient's back and front, respectively. Monitors, the camera apparatus, the videocassette recorder, and insufflation equipment are then connected. An insufflator is placed within the peritoneal cavity either under direct vision or with the Veress needle in the subcostal position, and the abdomen is insufflated with carbon dioxide gas. Under videoscopic monitoring, the surgeon places the first three intraperitoneal instrument ports equidistantly in a transverse line from the lateral edge of the rectus sheath to the midaxillary line between the costal margin and the iliac crest. The distance between each port should be 5 cm or more. Large 11- or 12-mm ports are used to accommodate camera, retractors, or the Harmonic scalpel. The peritoneal cavity is examined. A fan retractor may be placed through a medial port to retract the viscera medially, anteriorly, and superiorly. Operating instruments, grasping forceps, dissecting forceps, and an irrigation/suction apparatus are alternately placed within the abdomen through the lateral port.
In a laparoscopic right adrenalectomy, a fourth port is placed at the posterior axillary line into the retroperitoneum under direct vision. The right lobe of the liver is mobilized off the retroperitoneum up to the diaphragm and is retracted anteriorly and medially with a retractor. The adrenal gland is identified posterolateral to the inferior vena cava and superior to the kidney. The right adrenal is dissected from the superior pole of the kidney and the inferior vena cava. The right adrenal vein is identified coming off the vena cava and is doubly clipped and ligated. A second, smaller right adrenal vein is often identified superior to the main vein. Soft tissue attachments are divided, and the adrenal is placed in an endoscopic retrieval bag, which is extracted through one of the ports. The adrenal bed is checked for hemostasis, and the retractor, instruments, and videoscope are withdrawn. The operation concludes with closure of the fascial and skin defects.
Left adrenalectomy is performed with opposite patient position and port placement. The spleen is mobilized carefully and is reflected medially. The surgeon must not mobilize the kidney posteriorly because this maneuver will cause the kidney and adrenal gland to fall medially. This situation makes dissection of the adrenal gland extremely difficult. The spleen, the tail of the pancreas, and the stomach may be retracted anteriorly and superiorly with a fan retractor. The splenic flexure of the colon is then mobilized, to allow the left colon to fall inferiorly and anteriorly, away from the retroperitoneum. A fourth port may then be safely placed in the posterior axillary line. The rest of the procedure is performed similarly to a laparoscopic right adrenalectomy.
Complications
- Bleeding: the most common complication with laparoscopic approach, and the commonest to convert to open one.
- Injury to the tail of pancreas.
- Adrenal insufficiency
- Injury to the diaphragm.
- Pneumothorax.
- Wound infection.
- DVT.
References
- Sabiston textbook of surgery, 17th edition, Townsend et.al.(e.d.), Elsevier-Saunders