Background

Before 1992, open adrenalectomy was the only choice for removing adrenal tumors. The historical evolution started with open bilateral exploration of the adrenal glands, usually through a laparotomy or bilateral posterior incisions, when imaging was not available, to a focused open approach when imaging was able to localize the tumor, once diagnosis of the adrenal condition was achieved by biochemical confirmation of hormonal excess.

In 1992, Michel Gagner performed the first laparoscopic adrenalectomy, combining the technologies of laparoscopy with the focused approach to the adrenal gland. Since then, many centres have adopted this technique as the first-line approach to adrenalectomy.

Indications

Adrenalectomies are performed for 3 large groups of pathologies:

1. hormone-secreting (functioning) adrenal tumours, such as Conn’s syndrome (aldosterone-secreting), Cushing’s syndrome (hypercorticolism), and pheochromocytoma (catecholamine-secreting),
2. non-functioning adrenal tumours (incidentalomas),
3. adrenal malignancies.

Laparoscopic adrenalectomy (LA) is ideally suited for removal of the first two groups of conditions. Patients benefit by having smaller wounds, less postoperative pain, faster recovery, and shorter hospitalization, as compared to open adrenalectomies.

LA is not suitable for primary adrenal cancers (because of risk of seeding and recurrence), very large adrenal tumours (> 8-10 cm in size because of increased risk of malignancy), or in children (because of the relative small body size and large tumours that are potentially malignant, e.g. neuroblastoma). Open adrenalectomy still has a primary role for these conditions.

LA is now even attempted in complex adrenal tumours, such as pheochromocytoma, bilateral adrenal tumours (performing bilateral adrenalectomies), and cortical preservation in some adrenal conditions (e.g. bilateral sporadic pheochromocytoma).

Technique

Prior to surgery, the patient has to be well-prepared in terms of control of hypertension with anti-hypertensive drugs, and especially with pure alpha-blockade drugs (phenoxybenzamine) for pheochromocytoma.

We perform the laparoscopic transabdominal approach with the patient in the lateral position. With a left adrenalectomy, the patient is positioned left side up. A nasogastric tube is inserted for gastric decompression. The operating table is flexed at the waist and a cushion is positioned under the flank, to increase the distance between the costal margin and iliac crest.

Four ports are positioned just under the left costal margin evenly spaced apart. A 10-mm port is used for the scope, and the remaining 5-mm ports are for the graspers and ultrasonic dissector that we routinely use to aid in dissection. The lateral margin of the spleen is dissected (entering the retroperitoneal space by incising the posterior peritoneum) all the way up to the diaphragmatic crus. This enables the spleen and pancreatic tail complex to fall medially, thereby exposing the adrenal gland. Further dissection exposes the edges of the gland and this is traced down to the position of the adrenal vein at the infero-medial part of the gland. The vein is doubly ligaclipped and divided with scissors. The rest of the gland and attached tumour is dissected off the psoas muscle, forming the base. The gland is removed in an endoscopic plastic bag inserted through the 10-mm port. A small suction drain is inserted through the lateral 5-mm port.

With a right adrenalectomy, the patient is positioned right side up. The four ports are placed just under the costal margin. The triangular ligament is incised and the liver is retracted upwards with a fan retracter to expose the adrenal gland with its short vein joining the inferior vena cava. The adrenal vein is clipped and divided, and the adrenal gland and tumour are removed in toto.

The patient is allowed oral fluids postoperatively and started on solids the next day. Most patients are capable of leaving hospital in one to two days.

Results

We started LA in 1996 at our center in the National University Hospital, Singapore. Recently in the past few years, there have been more cases of LA. Of the 25 LA cases, 64% were performed for Conn’s adenoma, 16% for pheochromocytoma, 12% for Cushing’s adenoma, and 8% for non-functioning cortical adenomas. We perform LA for all functioning tumours and have been successful with LA in 96%, having converted to open adrenalectomy in one patient with a large 6-cm right pheochromocytoma. Morbidity in our series included one patient with transient fever for 3 days, and there was no mortality.

The mean operating times averaged 89 minutes for Conn’s adenoma, to 148 minutes for pheochromocytoma. The mean hospital stay ranged from 2.1 days for Conn’s syndrome to 6.5 days for pheochromocytoma. Tumour sizes were generally largest for pheochromocytoma (mean 5.5 cm) compared to Conn’s adenoma (mean 1.8 cm).

Conclusions

LA has gained wide acceptance as the preferred approach for most adrenal tumours. Open adrenalectomy still has a role in some tumours. LA is successfully performed for benign functioning or non-functioning tumours, and is beneficial for patients because of low morbidity and rapid recovery after surgery.