Introduction
The operative approach to adrenal cortical tumors must
be individualized according to the size and expected nature of the mass.
For many years, there have been four distinct surgical approaches from
which the surgeon could choose to gain access to the adrenal: anterior/transperitoneal,
thoracoabdominal, flank/retroperitoneal, and posterior (Fig 1).
1
The recent development of advanced laparoscopic instruments and techniques,
however, has made laparoscopic adrenalectomy the preferred method for resection
of most adrenal cortical and medullary tumors.
2-12 Each of these
diverse operative techniques continues to have a place in the surgical
management of these masses. The Table demonstrates how the situation at
hand usually plays a dominant role in dictating the appropriate surgical
approach. Other factors that may dictate the preferred technique to be
used include associated diseases, the overall health of the patient, bilaterality
and, of course, the surgeon’s familiarity with each procedure.
It has long been recognized that patients typically
experience a more uneventful hospital stay following the posterior and
flank approaches to the adrenal gland.1,2 This benefit has been
attributed to the avoidance of entry into the peritoneal cavity and less
tissue manipulation through the smaller, more localized operative field.
This more directed approach results in less postoperative pain, ileus,
and respiratory compromise as well as a hastened recovery compared to patients
undergoing a more formal anterior/transabdominal approach. The avoidance
of potential pancreatic injury and postoperative adhesion formation is
also attractive for these two techniques.
Nearly all of the benefits attributed to the retroperitoneal
and posterior approach to the adrenal can be expected to an even greater
degree following laparoscopic adrenalectomy. A number of studies have made
this comparison and demonstrated that removal of the adrenal by laparoscopy
is well tolerated, is associated with little postoperative pain, and typically
results in a remarkably quick return to normal function.9-14
These three routes are best suited for small- to moderate-sized masses
and are usually not appropriate for malignant lesions or large masses that
would require a large operative field for adequate exposure.
Anterior/Transabdominal Approach
The anterior/transabdominal approach remains the preferred
method for resection of large or malignant adrenal tumors.
15-17
Through the subcostal incision employed by most surgeons, excellent exposure
can be gained to the adrenal and its adjacent organs. The pancreas, spleen,
stomach, colon, kidney, and major visceral vascular structures can often
be involved within a malignant left adrenal mass, all of which can be accessed
through this approach. Similarly, the vena cava, duodenum, colon, and kidney
can be encroached upon by a right adrenal cancer necessitating adequate
anterior exposure. This approach also provides the exposure needed to assess
resectability in those patients with extremely large tumors or in those
in which preoperative imaging studies suggest the involvement of contiguous
structures.
Most surgeons prefer to reflect the spleen and body/tail
of the pancreas as well as the splenic flexure of the colon to the patient’s
right to gain direct access to the left adrenal. This technique allows
excellent exposure of the vascular pedicle of the kidney/adrenal and provides
the exposure to determine which structures may or may not need to be resected
en-bloc with a malignant mass to achieve adequate margins.
Adequate exposure is equally necessary for large
or malignant lesions of the right adrenal. Upward retraction of the liver
following complete mobilization of the right lobe is essential. Larger
lesions may require reflection of the duodenum and downward mobilization
of the hepatic flexure of the colon. These techniques are designed to allow
sufficient exposure of the adrenal arteries and the short right adrenal
vein. Care should be exercised with the right adrenal vein and the surgeon
should expect a number of large veins emptying directly into the vena cava
from large malignant lesions. A mechanical retractor greatly simplifies
the effort needed to gain exposure on the right or left, and of course,
wide exposure is the primary reason the transabdominal approach is selected.
Thoracoabdominal Approach
When extensive exposure is needed, as in the case of
giant malignant lesions, the thoracoabdominal approach will often provide
the only option for safe resection.
1,16 All incisions undertaken
for large tumors should be planned so that conversion to the thoracoabdominal
technique can be made. This method has all the drawbacks of both abdominal
and thoracic incisions, yet the exposure gained can be lifesaving. This
approach should not be undertaken lightly because of its high potential
for morbidity, yet when wide visualization of surrounding structures such
as the vena cava becomes necessary, there is no substitute.
Flank/Retroperitoneal Approach
The flank approach to the adrenal gland is a compromise
between minimal surgery through a limited incision and the wide exposure
gained through the transabdominal approach. Positioning is key to the successful
exposure of the retroperitoneal space and necessitates that the patient
is placed in a semidecubitus position. By flexing the operating table,
the costal margin and the iliac crest can be separated, thereby distracting
the organs within the operative field. This allows excellent visualization
of the adrenal gland and its anatomic neighbors on the operative side;
however, visualization of the contralateral gland is impossible. Therefore,
the flank approach is not appropriate for those patients who harbor bilateral
tumors. Similarly, the advantages gained by remaining in the retroperitoneal
space are probably lost if the greater peritoneal cavity is entered, necessitating
excessive manipulation of bowel.
16 Since exposure of the kidney
and its vascular pedicle is excellent, this approach is ideally suited
for medium-sized tumors and those that may involve the kidney. If the necessity
arises, conversion to the transabdominal procedure can be made without
much difficulty if the incision is planned well.
Posterior Approach
For a number of years, the posterior or lumbar approach
to the adrenal gland has been the favorite of many surgeons for the removal
of small- to medium-sized benign tumors. This technique is so well tolerated
that it is often used in a bilateral fashion utilizing two incisions when
the situation necessitates bilateral adrenalectomy.
2,10 The
12th rib is typically resected; however, care should be exercised to preserve
the accompanying neurovascular bundle since weakness of the lateral abdominal
musculature may result, giving the appearance of a large flank hernia.
This technique is usually not appropriate for malignant tumors because
of the limited operative field and the inability to assess or resect adjacent
structures. Laparoscopic surgery has recently supplanted the posterior
approach as the preferred method for removal of adrenal masses dictating
minimal surgery for benign disease.
Laparoscopic Adrenalectomy
Since 1993, several manuscripts have been published
touting the advantages of laparoscopic adrenalectomy. As experience has
been gained in this technique, surgeons have been applying it to larger
and larger cortical tumors and even pheochromocytomas (Fig 2). From the
more limited case reports to some of the more recent larger studies, one
thing is certain: this procedure is well tolerated by patients and results
in a dramatic recovery not seen following any other approach to this organ.
Nearly all studies report expected postoperative hospital stays of two
or three days, decreased blood loss compared to the open procedure, and
little if any need for narcotics beyond the first postoperative day.
4-7,10-13,
18,19
Several distinct laparoscopic techniques have been
proposed to gain access to the retroperitoneal adrenal glands. Although
many authors have suggested an approach that starts and remains retroperitoneal,
our preference -- as well as that of the vast majority of authors reporting
on the subject -- is for standard transperitoneal laparoscopy with a directed
retroperitoneal dissection as discussed here. Regardless of the laparoscopic
approach, the patient must be put into a semilateral or lateral decubitus
position with the table broken to widen the space between the iliac crest
and the costal margin. Some surgeons are using a lateral decubitus position
without breaking the table. This may not always allow adequate exposure,
but a good operating table can be broken as needed. The induction of the pneumoperitoneum may be achieved
via a Veress needle placed through the flank. However, we prefer to roll
the table to permit better access to the umbilicus. A standard cut-down
is then performed to allow direct visual placement of the first cannula.
A large midline port is necessary for the placement of large-diameter instruments
such as staplers and clip appliers, so the umbilical cut-down provides
this needed access. The remainder of the dissecting ports are subsequently
placed with the table rotated back to its normal position, leaving the
patient with an exposed flank. At least three additional ports will be
needed, all of which are placed below the costal margin within the confines
of the axillary lines (Fig 1). It is often surprising to find just how
high the adrenal glands are located in the retroperitoneum. Ports placed
more than a few finger breadths below the costal margin may need to be
replaced later as one realizes that standard laparoscopic instruments will
not reach the normally positioned adrenal. We prefer to use a large port
placed in the anterior axillary line for the camera, allowing the surgeon
to be situated to the patient’s back while operating through the two more
posterior ports.
The right adrenal gland is found rather easily once
the right lobe of the liver is mobilized. A fan retractor aids in keeping
the liver out of the operative field and should be inserted through a new
port placed for this purpose if necessary. The hepatic flexure of the colon
rarely needs to be mobilized, which is also true of the duodenum. By downward
traction on the peritoneum overlying the kidney, the adrenal gland is easily
visualized. The removal of this gland is straightforward, but the right
adrenal vein is short and can make ligation difficult. We prefer to use
an Endo-GIA (United Stated Surgical Corp, Norwalk, Conn) type of vascular
stapling device on the right adrenal vein to provide a more secure ligation,
while others use clips.
Access to the left adrenal can be achieved in two
ways. The first requires the splenic flexure of the colon to be mobilized
so it can be reflected medially and inferiorly. The descending colon does
not need to be fully mobilized, since the aim is to uncover the inferior
edge of the pancreas where the kidney and adrenal will be found. Another
option is to proceed directly through the peritoneum overlying the distal
transverse mesocolon. Either way, the inferior boarder of the pancreas
must be seen. The vein on the left is considerably longer and easily lends
itself to safe transection between clips. We have found that the actual
dissection of the adrenal from surrounding structures is made considerably
easier with significantly less blood loss with the use of a harmonic scalpel.12,20
Once free, removal of the mass from the abdominal cavity is facilitated
by placement into a specimen bag and enlargement of one of the flank port
sites using muscle-splitting techniques.
Learning Laparoscopic Adrenalectomy
Laparoscopic adrenalectomy is an advanced laparoscopic
technique. The use of angled cameras and multiple instruments simultaneously
can be challenging. Fig 3 shows the time required by the authors to laparoscopically
resect left and right adrenal glands. A significant learning curve is apparent
in that an improvement is seen for the first 10 cases on each side after
which no further improvement is seen. This learning curve has been described
previously,
21 but others have suggested further improvement
through a surgeon’s first 15 cases on each side. Also note that the left
side requires significantly more dissection of adjacent organs, thereby
increasing the total operative time over laparoscopic right adrenalectomy.
Indications
With the vast number of adrenal lesions found in asymptomatic
patients, the consideration is always one of diagnosis and resection vs
repeated follow-up examination.
22-25 The ability to remove small
lesions with little morbidity may have an impact on the management of these
potentially malignant lesions. Since the laparoscopic approach is typically
tolerated so well, it may be suited for many patients as the cutoff for
resection rather than long-term follow-up for these incidentalomas decreases
from 6 to 4 or even 3 cm.
22-24 Small- to moderate-sized functional
tumors in symptomatic patients also provide excellent candidates for laparoscopic
resection.
14, 26-28 One must also consider that an incidental,
nonfunctional lesion seen on magnetic resonance imaging may cause emotional
stress for the patient, and this stress may be relieved only by resection.
Laparoscopic adrenalectomy is an excellent solution for this unique situation.
The reported conversion rate from laparoscopic adrenalectomy
to open is 6.4%,18 which has been seen in our hands as well.
The most common reasons that the laparoscopic procedure cannot be carried
out to completion are the presence of intra-abdominal adhesions and a difficult
dissection, whereby the surgeon feels an open procedure will provide a
safer and more complete resection. The latter is more common in morbidly
obese patients. It has also been shown that a more experienced surgical
team decreases the amount of complications.18
Although advances in laparoscopic techniques have
provided a new approach to an old problem, its use should be applied appropriately.
The lack of wide exposure and tactile sensation leaves this method prone
to incomplete removal of malignant tumors. Because of these limitations,
we agree with the vast majority of authors who suggest that this method
of adrenalectomy be reserved for lesions with a small probability of malignancy.
This would typically mean that patients with lesions larger than 8 to 10
cm are not good candidates for a laparoscopic approach. Similarly, masses
that have radiographic signs of malignancy such as irregular boarders29
may be better approached through one of the more conventional methods.
Through the use of an individual approach for each patient and each adrenal
mass, the most appropriate operative technique, whether minimally invasive
or not, can be chosen to minimize morbidity while maximizing curative potential.
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