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Laparoscopic Adrenalectomy

  • Indications
  • Adrenal benign tumors (functional or non-functional) of relatively small volume (< 5 cm, larger tumors associated with increased risk of malignancy)
    • Aldosteronoma, pheochromocytoma, ganglioneuroma, lipoma
  • Adrenal Hyperplasia
  • Hormonal overproduction
  • The role of LA in the treatment of malignant adrenal tumors is still controversial. Several reports on LA for malignant adrenal tumors have revealed that the procedure is associated with a risk of tumor spillage, peritoneal or port site dissemination resulting in local recurrence . Despite the fact that tumor spillage is not universally accepted, no benefit in matters of oncological outcome has been demonstrated in case of LA versus open approach. Consequently, open adrenalectomy should be currently preferred in cases of pre-operatively diagnosed adrenocortical cancers.
  • A cutoff point of <5-6cm adrenal tumors have been empirically posed by many urologists for laparoscopic resection
  • Adrenal tumor size could pose a relative contraindication for two reasons.
    • Bigger adrenal lesions are associated with higher possibility of a misdiagnosed malignancy.
    • Increased operative time, perioperative blood loss, and conversion to open surgery rate have been reported in the case of large (>5cm) adrenal lesions in comparison to smaller lesions. Nevertheless, operative time, blood loss, hospital stay, and complication rate are always reported to be lower for laparoscopic adrenalectomy in comparison to the conventional open adrenalectomy for large tumors. Moreover, the growing laparocopic skill and clinical experience resulted in successful laparoscopic management of tumors up to 12 cm in diameter. Thus, the size of benign tumors that are treated by the laparoscopic approach are depending on the clinical experience of the performing surgeon.

  • Surgical Steps
  • 1. Positioning of patient
    • Same position as laparoscopic radical nephrectomy
  • 2. Trocar placement (similar positions for Right and Left adrenalectomy, inversed sides)
    • Use Veress needle or open Hassan Technique to establish pneumoperitoneum
    • Lateral margin of the rectus muscle in a site cranially to the level of the umbilicus (10mm trocars).
    • Mid- axillary line near the costal margin (12mm trocar)
    • Costal margin towards the xiphoid near the pararectal line (5mm trocar)
  • 3. Right Laparoscopic Adrenalectomy
    • Elevation of right lobe of the liver using fan retractor inserted via the medial port
    • Incision of the triangular ligament down to the level of the diaphragm
    • Dissection of gland begins medially, between adrenal, IVC and cephalad to the liver
    • Identification and ligation (clipping) of adrenal vein
    • Continuation of dissection, medially, superiorly and inferiorly – clips or electrocoagulation is vessels are encountered
    • Separation of kidney at end of procedure, insertion into retrieval bag and extraction
  • 4. Left Laparoscopic Adrenalectomy
    • Patient positioning and trocars placement inversed in relation to Right Laparoscopic Adrenalectomy
    • Mobilization of colon’s splenic flexure
    • Division of attachments to spleen and tail of pancreas using electrocautery
    • Identification and ligation of left adrenal vein (flowing into left renal vein).
    • Division of adrenal gland’s attachments
    • Retrieval with specimen bag

  • Tips and Tricks
  • Control of bleeding is essential in any surgical case, but especially so in laparoscopic surgery where the vision of the operative field may be obscured very quickly by hemorrhage
  • For left adrenalectomy, the spleen should be completely mobilized in order to gain better access to the operative field
  • On the right side, use the vena cava as a guide to finding the the renal and adrenal veins
  • Beware of segmental renal veins to the upper pole, they may be confused for the adrenal vein.
  • The left adrenal vein is usually more easily discerned than the right adrenal vein
  • Although three distinct arterial branches (Superior, Middle and Inferior adrenal arteries) are classically described, there may be a wide range of variations, with an arcade of arteriolar branches commonly seen in the superior surface of the adrenals. These may be ligated with an ultrasonic shears.
Clinical Videos
Laparoscopic adrenalectomy right side