INTRODUCTION Compared with the traditional open resection, laparoscopic adrenalectomy has decreased requirement for postoperative analgesia and is characterized by a shorter hospital stay, better patient satisfaction, and an earlier return to normal diet and activities.2<\/sup> These clear advantages of laparoscopic adrenalectomy did not encourage any prospective randomized controlled trials comparing the new technique with the classical \u2018open\u2019, either transabdominal or retroperitoneal technique.<\/p>\n We present a single institution\u2019s experience on a relatively large number of laparoscopic adrenalectomies.<\/p>\n PATIENTS AND METHODS<\/strong><\/span><\/p>\n From May 1997 to August 2005, ninety-five patients with adrenal tumors were referred to our Department and underwent adrenalectomy. Five patients underwent either synchronous or metachronous bilateral adrenalectomies. There were 38 men and 57 women, aged 16 to 80 years. The most common adrenal diseases were adenomas, pheochromocytomas, Cushing\u2019s syndrome, aldosteronomas, and malignant tumors (Table 1).<\/p>\n Technical aspects of Laparoscopic adrenalectomy Right adrenalectomy.<\/em> The right triangular ligament and the retroperitoneal liver attachments are cauterized and divided. After dividing the retroperitoneum, the inferior vena cava (IVC) is identified. This phase is very important, especially in obese patients with Cushing\u2019s syndrome, where the IVC is obscured by adipose tissue. The inferior periadrenal fat is carefully dissected from the upper pole of the right kidney and the renal vein is usually identified. The periadrenal fat is either grasped or pushed upwards. The adrenal vein is subsequently identified, dissected, double-clipped, and divided. The inferior and superior adrenal vessels are cauterized or clipped. Ultrasonic scissors are occasionally used.<\/p>\n Left adrenalectomy.<\/em> The left colonic flexure is mobilized, if necessary, and the left upper renal pole is exposed. The splenic attachments are cauterized and divided, and the tail of the pancreas is identified. The spleen is further mobilized until the stomach is visualized. Gerota\u2019s fascia is then opened, the adrenal gland identified and the adrenal vein dissected, double clipped, and divided. The renal vein is always identified prior to adrenal vein clipping. The upper adrenal vessels are either cauterized or clipped.<\/p>\n RESULTS<\/strong><\/span><\/p>\n In 73 patients laparoscopic adrenalectomy was completed successfully. Fourteen patients with either large or malignant tumors underwent open adrenalectomy not preceded by laparoscopic approach (Table 2). There were also 2 open adrenalectomies for incidentalomas, performed during a pancreatectomy and a colectomy for cancer, not included in this series. Two patients with adrenocortical carcinoma underwent en-block resection of adrenal tumor with the spleen and distal pancreas and en-block nephrectomy with adrenalectomy, respectively. Both patients were subjected to open approach from the start (Table 2).<\/p>\n In 8 cases the laparoscopic procedure was converted to an open approach primarily for the patient\u2019s safety as well as better surgical efficacy. One of these patients with macronodular bilateral adrenal hyperplasia underwent successful right adrenalectomy but the left laparoscopic procedure was converted to open. In one patient with a right adrenal adenoma and Cushing\u2019s syndrome, with history of repeat surgery for benign biliary stricture, convertion was necessary because of multiple adhesions. In seven patients presenting difficulty in identification of structures, the procedure was also converted to open approach. Of these 8 patients, 5 had Cushing\u2019s syndrome and 3 pheochromocytoma. There have been no conversions during the last 5 years.<\/p>\n The size of the tumors in our series ranged from 3.2 to 27 cm. The largest, laparoscopically excised tumor was a ganglioneuroma with a diameter of 13 cm.<\/p>\n Operative time for laparoscopic adrenalectomies ranged from 65 to 180 minutes (median 110 minutes). The average postoperative hospital stay for laparoscopic adrenalectomy ranged from 1 to 2 days (mean 1.5 days), versus 5 to 20 days in patients who underwent open or converted procedure.<\/p>\n One patient with pheochromocytoma developed pulmonary embolism three hours after the procedure and succumbed in the intensive care unit one month later. The patient initially underwent laparoscopic approach for an 8 cm tumor and was converted to open due to difficulty in mobilization and minor but troublesome bleeding obscuring the operative field. In one patient with morbid obesity, Cushing\u2019s syndrome, and bilateral macronodular adrenal hyperplasia, the right laparoscopic adrenalectomy was uneventful but the left laparoscopic adrenalectomy was converted to open and was complicated by a low output pancreatic fistula, treated conservatively.<\/p>\n At a mean follow-up interval of 52 months postlaparoscopic adrenalectomy (range 2-96 months), no evidence of benign tumor recurrence was observed.<\/p>\n One patient who had been treated for recurrent malignant pheochromocytoma developed local recurrence and extensive metastatic disease and died 18 months following his last operation. Patients with primary cortical adenocarcinoma survived for a period of 18 to 24 months. One patient with metastatic lung carcinoma survived 11 months. One patient with bilateral metachronous adrenal metastasis from colonic carcinoma, underwent bilateral adrenalectomy and is currently free of disease 4 years after the last adrenalectomy.<\/p>\n DISCUSSION Procedures in obese patients with Cushing\u2019s syndrome associated with adrenal hyperplasia require experience in laparoscopic approach. Absence of the tactile sense and rigidity of the laparoscopic instruments may result in fragmentation of the gland and necessitate conversion to an open operation to avoid recurrence of the disease.4<\/sup> Most of our conversions to open surgery, although early in our experience, are patients with Cushing\u2019s syndrome. Intraoperative ultrasonography is reported to be useful in locating the adrenal gland, especially in complex cases, during the surgeon\u2019s \u2018learning curve\u2019.5 From a technical standpoint, large adrenal masses are difficult to dissect laparoscopically. In our series the largest tumor resected laparoscopically was a 13 cm ganglioneuroma, which was our sixty-fifth laparoscopic adrenalectomy. The patient was a young woman with a large, benign on CT tumor, discharged on the second postoperative day. Several authors limit the laparoscopic adrenalectomy to lesions less than 6 cm in size,12<\/sup> whereas others perform laparoscopic adrenalectomy on tumors up to 13 cm in diameter, with no morbidity.5,13<\/sup> Extensive experience in advanced laparoscopic techniques and in open adrenal surgery are mandatory to manipulate and excise large tumors with a laparoscopic approach.<\/p>\n At present, laparoscopic adrenalectomy for invasive malignant tumors is contraindicated.14<\/sup> En-block extensive resections as nephrectomy, hepatectomy and splenectomy are not well suited to the laparoscopic technique.15<\/sup> Several cases of laparoscopic adrenalectomy for malignant tumors, followed by local recurrence and disseminated abdominal carcinomatosis within a few months, have been published.16<\/sup> On the other hand, series of laparoscopic adrenalectomies for metastatic adrenal tumors, followed for 0.5 to 19 months without recurrence, have been reported.17 REFERENCES<\/strong><\/span><\/p>\n 1.\u00a0\u00a0 \u00a0Gagner M, Lacroix A, Bolte E, 1992 Laparoscopic adrenalectomy in Cushing\u2019s syndrome and pheochromocytoma. N Engl J Med 327: 1033. George N. Zografos, Athina Markou, Chrisanthi Ageli, Nikos Kopanakis, Spiros Koutmos, Gregory Kaltsas, George Piaditis, George I. Papastrati<\/p>\n
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\nThe first laparoscopic adrenalectomy was performed by Michel Gagner in 1992.1<\/sup> Since then it has become a standard surgical approach for benign adrenal tumors.<\/p>\n
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\nWe prefer the transperitoneal lateral decubitus approach as being the best for maximal exposure of the gland. We start with three 10mm trocars, introducing a fourth 5mm one, if necessary, at a later stage.<\/p>\n
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\nLaparoscopic adrenalectomy has rapidly replaced open adrenalectomy as the procedure of choice in benign adrenal tumors. Associated morbidities, such as morbid obesity, bleeding disorders or previous abdominal procedures, are considered as relative contraindications.3<\/sup> In our series, three of four patients with previous upper abdominal surgery were successfully treated laparoscopically.<\/p>\n
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\nThe size at which an incidentally detected adrenal tumor requires excision ranges from 2.5cm to 6cm in various institutions.6-8<\/sup> Although principles in surgery should not change with the introduction of a new technique, we witnessed a trend toward surgical referral earlier in the course of adrenal diseases.9<\/sup> An increase in the number of laparoscopic adrenalectomies in the United States without concomitant increase in the incidence of adrenal cancer has recently been reported.10
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\nGagner and associates consider that non-functional tumors over 3 cm in young and fit patients should be resected.5<\/sup> Others suggest that, in view of the safety and efficacy of laparoscopic approach, all tumors larger than 2.5 or 3 cm should be excised laparoscopically.8<\/sup> We currently resect tumors either hormonally active or larger than 4cm, and even smaller if they appear suspicious for malignancy on computerized tomography. In an extensive literature search we found only one case of adrenal incidentaloma, benign in imaging, sized less than 4 cm, which proved to be malignant.11<\/sup> However, in young patients we advocate surgery for smaller tumors in view of a long-term follow-up and the concomitant patient\u2019s anxiety.<\/p>\n
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\nAlthough most institutions perform open procedures for adrenal cancer, the number of laparoscopic adrenalectomies carried out for malignant tumors is a notable phenomenon of the last few years.18<\/sup> However, the series are not large, the results are conflicting, and there are no prospective trials. At present, laparoscopic adrenalectomy is an acceptable approach for metachronous solitary metastasis of a variety of primary tumors.19
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\nEarly ligation of the central adrenal vein to facilitate pharmacologic control in pheochromocytoma has been emphasized in reports and textbooks. One of our patients with an 8 cm pheochromocytoma developed hypertension during laparoscopic adrenalectomy, successfully treated with hydralazine.20<\/sup> An extensive search of the literature showed that hemodynamic instability during surgery has been successfully treated.21<\/sup> Other investigators suggest that laparoscopic approach to pheochromocytoma decreases the intraoperative release of catecholamines compared to open technique, therefore minimizing the risk of hypertensive crisis.22
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\nLaparoscopic adrenalectomy is currently the gold standard for all benign adrenal diseases. Our series confirms that laparoscopic adrenalectomy is a safe and effective procedure associated with low morbidity, short hospital stay, and recovery. However, the procedure necessitates experience in open adrenal surgery, advanced laparoscopic techniques, and familiarization with new technologies. Careful preoperative planning and support from the endocrinology team minimize the occurrence of intraoperative or postoperative complications.<\/p>\n
\n2.\u00a0\u00a0 \u00a0Thomson GB, Grant CS, van Heerden J, et al, 1997 Laparoscopic versus open posterior adrenalectomy: a case-control study of 100 patients. Surgery 6: 132-136.
\n3.\u00a0\u00a0 \u00a0Schell SR, Talamin MA, Udelsman R, 1998 Laparoscopic adrenalectomy. In: Advances in surgery. Mosby-year book Inc 32: 333-350.
\n4.\u00a0\u00a0 \u00a0Wells SA, Merke DP, Cutler GB, Norton JA, Lacroix A, 1998 The role of laparoscopic surgery in adrenal disease. J Clin End Metab 83: 3041-3043.
\n5.\u00a0\u00a0 \u00a0Gagner M, Pomp A, Heniford BT, Pharand D, Lacroix A, 1997 Laparoscopic adrenalectomy. Lessons from 100 consecutive procedures Ann Surg 226: 238-247.
\n6.\u00a0\u00a0 \u00a0Staren ED, Prinz RA, 1995 Selection of patients with adrenal incidentalomas for operation. Surg Clin N Am 75: 499-509.
\n7.\u00a0\u00a0 \u00a0Barry MK, van Heerden JA, Farley DR, Grant CS, Thompson GB, Ilstrup DM, 1998 Can adrenal incidentalomas be safely observed? World J Surg 22: 599-604.
\n8.\u00a0\u00a0 \u00a0Rutherford JC, Gordon RD, Stowasser M, et al, 1995 Laparoscopic adrenalectomy for adrenal tumors causing hypertension and for \u2018incidentaloma\u2019 of the adrenal on computerized tomography scanning. Clin Exp Pharmacol Physiol 22: 490-492.
\n9.\u00a0\u00a0 \u00a0Brunt LM, Moley JF, 2001 Adrenal incidentaloma. World J Surg 25: 905-913.
\n10.\u00a0\u00a0 \u00a0Saunders BD, Wainess RM, Dimick JB, et al, 2004 Trends in utilization of adrenalectomy in the United States: Have indications changed? World J Surg 28: 1169-1175.
\n11.\u00a0\u00a0 \u00a0Kasperlik-Zaluska AA, Migdaska BM, Makouska AM, 1998 Incidentally found adrenocortical carcinoma. A study of 21 patients. Eur J Cancer 34: 1721-1724.
\n12.\u00a0\u00a0 \u00a0Ting ACW, Lo CY, Lo CM, 1998 Posterior or laparoscopic approach for adrenalectomy. Am J Surg 175: 488-490.
\n13.\u00a0\u00a0 \u00a0Porpiglia F, Garrone C, Giraudo G, et al, 2001 Transperitoneal laparoscopic adrenalectomy: experience in 72 procedures. J Endourol 15: 257-259.
\n14.\u00a0\u00a0 \u00a0Raeburn CD, McIntyre RC, 2000 Laparoscopic approach to adrenal and endocrine pancreatic tumors. Surg Cl N Am 80: 1427-1433.
\n15.\u00a0\u00a0 \u00a0Ganger M, 1996 Laparoscopic adrenalectomy. Surg Clin N Am 76: 523-537.
\n16.\u00a0\u00a0 \u00a0Iino K, Oki Y, Sasano H, 2000 A case of adrenocortical carcinoma associated with recurrence after laparoscopic surgery. Clin Endocrinol 53: 243-248.
\n17.\u00a0\u00a0 \u00a0Heniford BT, Arca MJ, Walsh RM, Gill IS, 1999 Laparoscopic adrenalectomy for cancer. Semin Surg Oncol 16: 293-306.
\n18.\u00a0\u00a0 \u00a0Cobb WS, Kercher KW, Sing RF, Heniford BT, 2005 Laparoscopic adrenalectomy for malignancy. Am J Surg 189: 405-411.
\n19.\u00a0\u00a0 \u00a0Sturgeon C, Kebebew E, 2004 Laparoscopic adrenalectomy for malignancy. Surg Clin N Am 84: 755-774.
\n20.\u00a0\u00a0 \u00a0Papastratis G, Zografos G, Koliopanos A, et al, 1998 Laparoscopic approach to the right pheochromocytoma. Surg Endosc: Suppl 12: 163.
\n21.\u00a0\u00a0 \u00a0Lezoche E, Guerriri M, Paganini AM, et al, 2000 Laparoscopic adrenalectomy by the anterior transperitoneal approach: results of 108 operations in unselected cases. Surg Endosc 14: 920-925.
\n22.\u00a0\u00a0 \u00a0Ramacciato G, Mercantini P, Pietromaria A, et al, 2005 Ten years of laparoscopic adrenalectomy: Lessons learned from 104 procedures. Am Surg 71: 321-325.<\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"