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nterior (Trans-Abdominal)aparoscopic Adrenalectomy

ohn C. Kairys, MD

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aparoscopic adrenalectomy has become the procedure ofchoice over open adrenalectomy because of the deep lo-

ation of the gland in the retroperitoneum and the small sizef most adrenal tumors. Most adrenal tumors can be removedith this technique by laparoscopic surgeons with appropri-

te technical skill and experience. Numerous studies havehown that the risk of complications and the overall out-omes are comparable or better than for open adrenalec-omy.1-6

For functional tumors of the adrenal cortex that are lesshan 4 to 6 cm in size, the risk of malignancy is low.7,8 There-ore, the potential for seeding malignant cells into the sur-ounding area or at port sites should also be very low. Ex-remely large tumors or tumors with marked heterogeneityn imaging, indistinct margins, or frank evidence of invasion,hould be approached in an open fashion.8 However, a num-er of recent studies have demonstrated that tumors largerhan 6 cm that do not demonstrate any obvious signs ofalignancy may be approached laparoscopically with a high

ate of success and with good clinical outcomes.9-15 For allumors in this larger size range, a frank discussion should beeld with the patient preoperatively to discuss the risks andenefits of a laparoscopic versus open approach, as well ashe possible need for conversion to an open procedure. Theudgment and experience of the surgeon is critical to theuccess of these procedures. Novice laparoscopic surgeons,r those without significant experience in adrenal surgery,hould approach these more challenging procedures withxtreme caution.

For patients with pheochromocytomas, appropriate pre-perative evaluation, medical management and adrenergiclockage is essential.16 These patients require intraoperativerterial blood pressure monitoring and central venous accesso administer vasoactive agents, as required. Excellent com-unication with the anesthesia team is essential. A slaveonitor displaying hemodynamic information placed adja-

ent to the working monitor (or available as an inset on theain video screen) is ideal. Because pheochromocytomas areore commonly benign as compared with similarly sized

drenocortical tumors, patients with larger sized tumors may

epartment of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.ddress reprint requests to John C. Kairys, MD, Department of Surgery, Thomas

Jefferson University Hospital, 1025 Walnut Street, Room 100, College

uBuilding, Philadelphia, PA 19107. E-mail: John.Kairys@jefferson.edu

04 1524-153X/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.doi:10.1053/j.optechgensurg.2007.10.001

e candidates for laparoscopic resection. Whereas previoustudies suggested an upper size limit of 8 cm for a laparo-copic approach,17-19 more recent studies have suggested thatumors as large as 12 cm can be safely resected with thisechnique.20-24 Once again, the experience and judgment ofhe surgeon are critical to success.

Isolated metastatic lesions of the adrenal are uncommon,ut these tumors may also be removed laparoscopically. Asith any carcinoma, there is concern that cells could be re-

eased during laparoscopic dissection and manipulation ofhe gland. However, a number of small studies have demon-trated that laparoscopic adrenalectomy can be performed inarefully selected patients with a low risk of local recur-ence.25,26

Laparoscopic approaches to the adrenal gland include annterior (trans-abdominal) approach and the posteriorretroperitoneal) approach.27-29 The anterior approach as dis-ussed here is the easiest learned as it is based on familiarandmarks and anatomical relationships. Extensive prior up-er abdominal surgery may be a relative contraindicationecause the upper abdominal organs may not be able to fallut of the way without performing an extensive lysis of ad-esions. The posterior approach offers the benefit of not en-ering the abdominal cavity at all, but is not as familiar toost general surgeons and offers limited working space and

ewer anatomic landmarks. It should be noted, though, thaturgeons who have gained significant experience with thisechnique demonstrate benefits with decreased operativeime and rapid recovery for the patient.30-33 In situations ofnfavorable anatomy (eg, the combination of a very largeight lobe of the liver with a very high adrenal, patients withoncomitant liver disease, or patients with splenomegaly),he posterior approach may be preferable.

The surgeon must be completely familiar with the anatomyf the adrenal regions bilaterally, and must be able to con-eptualize the anatomical relationships of the surroundingtructures despite the patient’s lateral position. Careful studyf the preoperative imaging studies is required to understandhese relationships and to recognize the unique features ofhe gland in each case.

The operation requires only a few laparoscopic instruments: aarmonic scalpel, DeBakey grasping forceps, medium-largelip applier, and suction irrigator. A 30-degree telescope is

tilized to provide varied visualization angles during the

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Laparoscopic adrenalectomy 105

ase. On the right side, a Diamond-Flex (Snowden Pencer,ublin, OH) or fan-type retractor is required.

ositioninghe patient is placed on the operating table in a lateral decu-itus position with the operative side up. A suction bean-bagnd appropriate padding of the axilla, arms, and legs are usedo maintain the patient in position. The bean-bag should beept down against the table in the region of the abdomen, tollow full expansion of the abdominal cavity. This allows thenternal organs adequate space to fall away from the area ofissection.

eft Adrenalectomyn the left side, three port sites are placed along the subcostalargin (Fig 1A). These incisions are placed about 2 to 3nger-breadths below the costal margin. I prefer to use 10 to2 mm ports for all sites to permit maximum flexibility withegard to instrumentation. The middle port is placed firstsing an open cannulation technique, and is located justedial to the anterior axillary line. The medial most port is

or the camera, and should be at least 5 to 10 cm off theidline, depending on the habitus of the patient, to allow

ree access for the camera as the spleen and pancreas fallorward during mobilization. Lastly, the lateral port is placeds lateral as needed to provide a good working angle after thenternal organs are visualized.

The principal means of providing exposure of the gland iso release the spleen and pancreas from their lateral and pos-erior attachments, thus allowing these organs and their sur-ounding tissues to fall forward by the effect of gravity.obilization begins by incising along the spleno-phrenic lig-

ment, about 1 cm from the edge of the spleen. This allows acuff” of the ligament to be used to manipulate the spleenuring mobilization (Fig 2). This ligament will need to beobilized until the fundus of the stomach is visible to allow

he spleen to fully fall anteriorly. A variable length of thehite line of Toldt may also need to be opened with corre-

ponding mobilization of the colon to allow the spleen andolon to fall forward as a unit. In general, it is not neces-ary to mobilize the colon below the inferior pole of theidney. Additionally, in some patients, division of the lat-ral aspect of the spleno-colic ligament may be beneficialo provide a better exposure of the renal hilum and thenferior aspect of the adrenal gland (Fig 3). Throughouthis mobilization, it is imperative to leave the posterolat-ral attachments of Gerota’s fascia intact so that the kidneyoes not fall forward.Successful exposure is contingent on identifying, entering,

nd staying in the loose layer of areolar tissue that separates thepleen, pancreas, and colon from Gerota’s fascia and the adrenalland and kidney below. This plane has relatively few bloodessels and a gentle sweeping motion of the instruments is gen-rally sufficient to achieve most of this mobilization. Great careustbetakenwhilemobilizingtheposterioredgeof thepancreasas

he operator will be extremely close to, and will likely visualize, theplenic artery and vein during the course of the dissection.

Once the spleen, pancreas, and colon are fully mobilized

orward, Gerota’s fascia and the underlying shape of the ad- a

enal and kidney should be visible. Dissection of the adrenalegins at its infero-medial aspect to identify and control thedrenal vein (Fig 4). Gentle dissection is mandatory to avoidearing the multitude of small vessels that pass through theatty tissue surrounding the adrenal gland. A combination oflunt dissection and use of the harmonic scalpel is mostseful in this area. The adrenal vein on the left side is a fairlyonstant structure, and its location often can be discerned byluntly elevating the adrenal gland with the left hand and

ooking for the bulge of the vessel as it is placed on stretchetween the renal vessels (the pulsation of which is a useful

andmark) and the adrenal gland. This area is carefully dis-ected, and the vein is doubly clipped and divided.

Mobilization of the gland may now be performed along itsedial aspect, using the harmonic scalpel to both dissect andivide the small arterial branches supplying the gland. Dis-ection proceeds as far superior as permitted by the anatomyf the particular gland. Dissection is then also performedlong the inferior aspect of the gland to separate it and elevatet from the antero-medial and superior aspects of the kidneyFig 5). Dissection should be directed fairly close to the ad-enal to avoid injury to any segmental arterial branches sup-lying the upper pole of the kidney. Division of theseranches can lead to hypoperfusion of the upper pole andesultant postoperative hypertension.

Meticulous dissection and hemostasis is necessary in thisrea to avoid bleeding that could then lead to clumsy at-empts to secure hemostasis, thus potentially injuring thenderlying renal vasculature. Throughout the case, the adre-al gland should be manipulated bluntly with the forceps.he fatty tissue and fascia surrounding the gland may berasped gently, but tearing of the tissue is common if theanipulation is not done carefully. Finally, the adrenal isobilized from the upper pole of the kidney by dividing theerinephic fat with the harmonic scalpel back to the level ofhe diaphragm. The supero-lateral attachments of Gerota’sascia are divided to complete the mobilization.

ight Adrenalectomyositioning for a right adrenalectomy is the opposite of leftdrenalectomy. Ports are also placed along the subcostal mar-in, although the two medial ports must often be placed aittle more inferiorly and further from the midline (Fig 1B).his allows the 30-degree telescope, which is placed through

he most medial port, to pass below the anterior edge of theiver. The two middle ports are used for the operating instru-

ents. A fourth 5 mm port is placed far laterally for a Dia-ond-Flex retractor.Alternatively, a fan-type retractor may be placed through

he most medial port, with the camera and other workingnstruments shifted laterally. However, I find that this ar-angement requires the operator to reach quite far over theatient with his or her left arm and can be ergonomicallywkward, particularly with a large patient.

Exposure of the right adrenal is accomplished by first mo-ilizing the lateral and inferior peritoneal attachments to the

iver using the harmonic scalpel. Sufficient mobilization muste done along the lateral aspect of the liver so that the retrac-or can elevate the right lobe cephalad and anteriorly from the

drenal gland (Fig 6). It is frequently necessary to mobilize

106 J.C. Kairys

Figure 1 Positioning of the patient for left (A) and right (B) laparoscopic adrenalectomy. Note the use of an axillary roll

and suction beanbag device, flexion of the table, and trocar placement.

Laparoscopic adrenalectomy 107

Figure 2 Relationship of anatomic structures on the left side. Note the line of incision through the peritoneal reflectionand splenocoloic ligament needed to expose the adrenal gland. The lateral edge of Gerota’s fascia must be kept intact

to prevent the kidney from falling forward.

Figure 3 Exposure of the Gerota’s fascia and the underlying adrenal gland once the spleen and pancreas have beenmobilized. Note the close proximity of the pancreas and splenic vessels to the anterior surface of the adrenal. In somecases, the tail of the pancreas may be mistaken for the adrenal during the initial mobilization. Careful attention to the

plane of dissection and the relationship to the underlying kidney will help avoid this error.

108 J.C. Kairys

Figure 4 Incision of Gerota’s fascia to gain control of the adrenal vein. The relationship to the renal vessels (and thepulsation of the renal artery) generally helps with the initial identification of the adrenal vein. The line of dissection

medially and laterally follows closely along the edge of the adrenal gland.

Figure 5 Mobilization of the adrenal from the upper pole of the kidney. The renal capsule is frequently exposed during

the course of the dissection. Care must be taken to avoid injury or division to any upper pole renal vessels.

Laparoscopic adrenalectomy 109

Figure 6 Relationship of anatomic structures on the right side. Note that the lateral attachments of the liver must beincised, frequently extending quite superiorly, to allow the liver to be retracted sufficiently cephalad. Except fordividing the superior attachments of the hepatic flexure, the lateral aspect of the right colon generally does not require

much mobilization.

Figure 7 The posterior peritoneum is incised to expose the adrenal gland. Although initial mobilization along the edgeof the vena cave is described in the text, an alternate approach is to mobilize the upper edge of peritoneum, just below

the posterior liver edge, as the initial step.

110 J.C. Kairys

Figure 8 Mobilization of the inferior aspect of the adrenal and division of the adrenal vein. The vein can be controlledeither with surgical clips, or with a vascular stapler, if it is very broad. Care should be taken to not past-point with theendo-shears as this vein is divided, as there are frequently numerous small adrenal arterial branches passing behind this

region.

Figure 9 Division of the superior attachments of the adrenal gland. The under surface of the diaphragm will become

visible as the gland is mobilized inferiorly.

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Laparoscopic adrenalectomy 111

he lateral aspect of the liver up to the tendinous portion ofhe diaphragm in order to provide adequate exposure of thedrenal. Next, the peritoneum is incised over the vena cava,nd this incision is extended upward along the lateral edge ofhe vena cava to the bottom edge of the liver. The origin ofenal vein is often seen during this initial exposure, and thisrovides a reference point to establish where the lower edgef the adrenal will be found, based on preoperative imagingtudies. In most patients, the duodenum spontaneously fallsorward and out of the operative field. However, in someatients with a broad or prominent duodenum, it may beecessary to perform a Kocher maneuver to obtain adequatexposure (Fig 7).

Sharp and blunt dissection is now performed along theateral edge of the vena cava until the lower edge of thedrenal gland is encountered. Seen from this lateral position,he gland appears to lie behind (posterior to) the edge of theena cava and the medial aspect of the gland is often initiallyidden from view. Dissection continues upward until the

arge, and typically very short, adrenal vein is visualized. Thiss carefully dissected free, and may be controlled with clipsr, as when the vein is particularly short, with a vasculartapling device (Fig 8). Once the vein is controlled, dissectionontinues along its upper edge until the superior-most extentf the gland is freed (Fig 9). An accessory adrenal vein isometimes found near the apex of the gland. Rarely, the sizef these veins reversed, with the superior-most vein being

Figure 10 Mobilization of the adrenal from the upperharmonic scalpel is useful in this area to control the muregion. As on the left side, care must be taken to avoid

ignificantly larger in caliber. A small sized adrenal vein s

ound inferiorly should alert the operator to this possibility. Ithould be noted that the instruments are often inserted toearly their full length to reach the adrenal vein and thepper edge of the gland. Decreasing the insufflation pressure

s sometimes helpful to allow the operator better control ofhe instruments during this important part of the procedure.

Once the supero-medial aspect of the gland has been freed,issection can proceed as previously described for the leftide. The peri-nephric fat along the inferior aspect of thedrenal is divided with the harmonic scalpel, once again tak-ng care to avoid injury to the underlying renal vasculatureFig 10). The gland is then elevated from the underlyingpper pole of the kidney. Gerota’s fascia and the remainingostero-lateral attachments are divided.For either side, the specimen is placed in a retrieval bag

nd removed through the initial, open port site, dividing theuscles as necessary to extract the specimen. The operative

ed is irrigated and checked for hemostasis. A drain may belaced through the posterior-most incision and left overnight

f a large volume of irrigation is used. This is done becauseost of the irrigation fluid falls dependently into the abdo-en and cannot be suctioned out. If a drain is not used, thisuid may leak from the posterior-most port site and can be aource of inconvenience to the patient and nursing staff afterhe patient is placed in the supine position. Port sites can belosed as per the preference of the operating surgeon.

Postoperatively, the patient may resume a normal diet as

of the kidney and underside of the diaphragm. Themall vessels that pass through the perinephic fat in thisto any underlying upper pole renal vessels.

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oon as they are able. Activities generally can be increased as

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112 J.C. Kairys

olerated but, because of the extensive mobilization of struc-ures on the left side, vigorous athletic activities should bevoided during the initial 1 to 2 weeks postoperatively. Pa-ients undergoing left sided adrenalectomy should also bencouraged to maintain good pulmonary toilet, as some de-ree of diaphragmatic splinting and resulting atelectasis isommonly observed.

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