Ausr. N.Z. J . Surg. (1994) 64,498-500 EXTRAPERITONEAL‘LAPAROSCOPIC’ ADRENALECTOMY MICHAEL KELLY, JOHN JORGENSEN, CHRISTOPHER MAGAREY AND LEIGH DELBRIDGE Endocrine Surgical Unit, St George Hospital, Kogarah, New South Wales, Australia The technique of extraperitoneal ‘laparoscopic’ adrenalectomy is described in two cases, a left sided 1 cm Conn’s tumour and a right sided 3.5 cm incidental non-functioning tumour. The extraperitoneal approach has the advantage of direct access to the adrenal gland without the need to mobilize abdominal organs, while maintaining all the advantages of minimal access surgery. Key words: adrenalectomy, laparoscopy. INTRODUCTION Adrenalectomy is an operative procedure ideally suited to ‘laparoscopic’ techniques. In the majority of cases, the sole requirement is the removal of an intact gland contain- ing a tumour. The gland has a well defined blood supply, the tumour is usually small, and the question of the adequacy of a functional result or the need for an anasto- mosis or reconstruction simply does not exist. The principal source of morbidity in open adrenalec- tomy is related to the access required to remove the tumour. The adrenal gland can be approached by an anterior transperitoneal route or by the extraperitoneal routes, either posterolaterally or posteriorly. Fahey, in the preceding paper,’ has already emphasized the advantages of the extraperitoneal approach in minimizing morbidity arising from open adrenalectomy. Most of the recent reports of laparoscopic adrenal- ectomy, however, have described a transperitoneal approa~h.~-~ While laparoscopy will minimize the need for a long incision, an anterior transperitoneal approach still requires extensive mobilization of a number of organs to obtain access to what is one of the most innaccessible of all abdominal organs. An extraperitoneal approach utilizing laparoscopic techniques has the advantages of both a minimal access procedure, together with the ease of direct access to the adrenal gland. The aim of this paper was to investigate and to describe the feasibility of extraperitoneal ‘laparos- copic’ adrenalectomy. PATIENTS AND METHODS Patients The first case was a 52 year old female, weighing 87 kg, presenting with primary hyperaldosteronism and a left Correspondence: Dr L. Delbridge, North Shore Medical Centre, 66 Pacific Hwy. St Leonards, NSW 2065. Australia. Accepted for publication 17 February 1994. adrenal tumour 1 cm in diameter. The second case was a 125 kg, morbidly obese female, presenting with a non- functioning, incidentally diagnosed, 3.5 cm right adrenal tumour (Fig. 1). Extraperitoneal ‘laparoscopic’ adrena- lectomy was performed through the left and right flanks, respectively, and the adrenal tumours were removed in both cases. Total anaesthetic and operating time was 3 h 17 min for the first case and 4 h for the second case. The patients were discharged on the 2nd and 3rd post-operative days, respectively, following an uneventful post-opera- tive course. Surgical technique Prior to undertaking the procedure in a clinical setting, the technique of extraperitoneal ‘laparoscopic’ adrenalec- tomy was developed during extensive work with pigs in the animal laboratory. The anaesthetized patient is placed in the lateral posi- tion on a kidney rest, which is then elevated to its maximal extent, flexing the spine laterally and opening out the relevant flank (Fig. 2). Port sites are marked as shown. For orientation, in Fig. 2 we have marked the costal margin with a dotted line, the iliac crest with a curved solid line, and the position of the surgical incision, should conversion to open extraperitonealadrenalectomy be required, with a straight line. A 20mm incision is made near the tip of the 12th rib in the mid axillary line, midway along the ‘open’ incision line as shown in Fig. 2 (heavy short straight line). The subcutaneous tissue is entered and the flank muscles are split in the direction of their fibres with finger dissection, in order to allow the passage of a finger tip into the retroperitoneal space. The perinephric tissues are then gently mobilized with the finger. Creation of the space is obtained in the following manner: a No. 8 surgical glove has the fingers and thumbs tied off and a large bore Foley catheter inserted and tied to make an air-tight seal. This is then placed through the initial incision into the peri- nephric space. Two litres of air are then injected into the glove using a syringe under firm pressure, allowing dissection of the retroperitoneal and perinephric tissues.
Transcript
Ausr. N.Z. J . Surg. (1994) 64,498-500
EXTRAPERITONEAL ‘LAPAROSCOPIC’ ADRENALECTOMY
MICHAEL KELLY, JOHN JORGENSEN, CHRISTOPHER MAGAREY AND LEIGH DELBRIDGE Endocrine Surgical Unit, St George Hospital, Kogarah, New South Wales, Australia
The technique of extraperitoneal ‘laparoscopic’ adrenalectomy is described in two cases, a left sided 1 cm Conn’s tumour and a right sided 3.5 cm incidental non-functioning tumour. The extraperitoneal approach has the advantage of direct access to the adrenal gland without the need to mobilize abdominal organs, while maintaining all the advantages of minimal access surgery.
Key words: adrenalectomy, laparoscopy.
INTRODUCTION Adrenalectomy is an operative procedure ideally suited to ‘laparoscopic’ techniques. In the majority of cases, the sole requirement is the removal of an intact gland contain- ing a tumour. The gland has a well defined blood supply, the tumour is usually small, and the question of the adequacy of a functional result or the need for an anasto- mosis or reconstruction simply does not exist.
The principal source of morbidity in open adrenalec- tomy is related to the access required to remove the tumour. The adrenal gland can be approached by an anterior transperitoneal route or by the extraperitoneal routes, either posterolaterally or posteriorly. Fahey, in the preceding paper,’ has already emphasized the advantages of the extraperitoneal approach in minimizing morbidity arising from open adrenalectomy.
Most of the recent reports of laparoscopic adrenal- ectomy, however, have described a transperitoneal approa~h.~-~ While laparoscopy will minimize the need for a long incision, an anterior transperitoneal approach still requires extensive mobilization of a number of organs to obtain access to what is one of the most innaccessible of all abdominal organs.
An extraperitoneal approach utilizing laparoscopic techniques has the advantages of both a minimal access procedure, together with the ease of direct access to the adrenal gland. The aim of this paper was to investigate and to describe the feasibility of extraperitoneal ‘laparos- copic’ adrenalectomy.
PATIENTS AND METHODS
Patients The first case was a 52 year old female, weighing 87 kg, presenting with primary hyperaldosteronism and a left
Correspondence: Dr L. Delbridge, North Shore Medical Centre, 66 Pacific Hwy. St Leonards, NSW 2065. Australia.
Accepted for publication 17 February 1994.
adrenal tumour 1 cm in diameter. The second case was a 125 kg, morbidly obese female, presenting with a non- functioning, incidentally diagnosed, 3.5 cm right adrenal tumour (Fig. 1). Extraperitoneal ‘laparoscopic’ adrena- lectomy was performed through the left and right flanks, respectively, and the adrenal tumours were removed in both cases. Total anaesthetic and operating time was 3 h 17 min for the first case and 4 h for the second case. The patients were discharged on the 2nd and 3rd post-operative days, respectively, following an uneventful post-opera- tive course.
Surgical technique Prior to undertaking the procedure in a clinical setting, the technique of extraperitoneal ‘laparoscopic’ adrenalec- tomy was developed during extensive work with pigs in the animal laboratory.
The anaesthetized patient is placed in the lateral posi- tion on a kidney rest, which is then elevated to its maximal extent, flexing the spine laterally and opening out the relevant flank (Fig. 2). Port sites are marked as shown. For orientation, in Fig. 2 we have marked the costal margin with a dotted line, the iliac crest with a curved solid line, and the position of the surgical incision, should conversion to open extraperitoneal adrenalectomy be required, with a straight line.
A 20mm incision is made near the tip of the 12th rib in the mid axillary line, midway along the ‘open’ incision line as shown in Fig. 2 (heavy short straight line). The subcutaneous tissue is entered and the flank muscles are split in the direction of their fibres with finger dissection, in order to allow the passage of a finger tip into the retroperitoneal space. The perinephric tissues are then gently mobilized with the finger. Creation of the space is obtained in the following manner: a No. 8 surgical glove has the fingers and thumbs tied off and a large bore Foley catheter inserted and tied to make an air-tight seal. This is then placed through the initial incision into the peri- nephric space. Two litres of air are then injected into the glove using a syringe under firm pressure, allowing dissection of the retroperitoneal and perinephric tissues.
EXTRAPERITONEAL LAPAROSCOPIC ADRENALECTOMY 499
Fig. 1. CT scan showing the 3.5 cm right adrenal tumour from patient No. 2 (marked with black arrow). Also demonstrated is the direct access obtained when the laparoscope is inserted through the flank.
Fig. 2. Photograph of the second patient in the lateral position with port placements marked (open circles for lOmm ports and short straight line for 20mm Hasson port), together with the costal margin (dotted line) and iliac crest (curved line).
The glove and cannula is withdrawn and a 20 mm Hasson cannula is inserted, after which insufflation of the space with C 0 2 gas is commenced. A 30” telescope is intro- duced and either three or four further lOmm ports are inserted. One port is placed inferiorly in the midaxillary line immediately above the iliac crest. The other ports are placed in the anterior and posterior axillary lines, the posterior being at the level of the Hasson cannula and the anterior as high as allowed by the costal margin. The
external siting of these ports is shown by open circles in Fig. 2. With the telescope placed in the inferior port. the retroperitoneal tissues are further mobilized with blunt dissection and diathermy.
At this stage the renal surface can be identified through the perinephric fat and is retracted inferiorly. Dissection is continued superior to the upper pole of the kidney and the adrenal gland identified, principally by its bright yellow, granular appearance. This was the most time- consuming part of the procedure, as the adrenal gland is often difficult to distinguish from the perinephric fat, especially if blood staining has occurred. Once located, dissection of the adrenal commences at its superior sur- face, allowing the gland to be retracted downwards with the kidney, to which it is still attached. As with open adrenalectomy, the most important principle is to ‘dissect the patient away from the adrenal gland’. Any direct holding or traction on the adrenal is to be avoided, as the gland is easily disrupted. The lateral and inferior surfaces are then mobilized, leaving usually only the medially placed adrenal veins attached. Any small arteries encoun- tered during the dissection are cauterized. Especial care needs to be taken on the right side as the right adrenal vein is generally short and passes directly into the inferior vena cava. The veins are divided between haemostatic clips, and the adrenal gland and tumour placed within a specimen retrieval bag before being delivered through the abdominal wall. A closed suction drain is inserted for 24h and the muscle and skin closed with absorbable sutures.
DISCUSSION The adrenal gland is one of the most innaccessible abdominal organs, and a number of different surgical approaches have been described. Most reports of laparos- copic adrenalectomy have described a transperitoneal approach. Gagner et al. reported three successful trans- peritoneal laparoscopic adrenalectomies for Cushing’s syndrome, Cushing’s disease and phaeochromocytoma2 and other a ~ t h o r s ~ - ~ have reported laparoscopic adrena- lectomy for Conn’s syndrome. Transperitoneal laparos- copic adrenalectomy, however, suffers from many of the same problems of access as does open anterior transperi- toneal adrenalectomy. On the left side, the splenic flexure of the colon usually requires mobilization, and the pan- creas may need to be retracted superiorly before the adrenal can be visualized. On the right side the liver must be retracted and the duodenum mobilized. In addition the short right adrenal vein may be difficult to isolate as it frequently enters the posterior wall of the inferior vena cava.
Extraperitoneal ‘laparoscopic’ adrenalectomy has the advantage of direct access to the adrenal glands on both sides without the need to retract or mobilize abdominal organs. The directness of this approach can be appreci- ated in Fig. 1, where the path of the laparoscope is shown in cross-section. It avoids the haemodynamic effects of pneumoperitoneum and the potential for injury to intra- peritoneal structures, and there is no need for urinary
500 KELLY ET AL.
catheters or gastric tubes. In our opinion the transperito- neal laparoscopic approach is technically a more difficult procedure requiring considerable dissection.
The technique of balloon dissection to create a work- able space in the retroperitoneum was described by Gaur,6 and has been successfully employed to perform nephrectomy.’ When used for adrenalectomy, the glove balloon dissector bloodlessly completes the major part of the retroperitoneal dissection, leaving only mobilization of the kidney and removal of the adrenal to be performed under direct visual control. The major disadvantage with the technique we have described is the relatively small working space, with subsequent technical restrictions imposed by having the ports placed close together.
The other advantages of minimal access surgery, namely, minimal post-operative pain, shorter hospital stay and rapid return to normal activities, are maintained with the extraperitoneal approach.
It is demonstrated in the present paper that extraperi- toneal ‘laparoscopic’ adrenalectomy is a feasible pro- cedure and the cases described are part of an ongoing clinical trial. As with open adrenalectomy, the authors believe that it is the preferred technique for access to this gland; however, further refinements to the technique are anticipated. It must be emphasized that the feasibility of removing an adrenal gland laparoscopically should not alter the normal clinical indications for adrenalectomy . For example, small (< 3 cm) non-functioning inciden-
tally discovered adrenal tumours (incidentalomas) should still be treated conservatively. At present, open extra- peritoneal adrenalectomy would be recommended for very large tumours (where removal via the port incision would be difficult), known malignant tumours or bilateral disease associated with Cushhg’s syndrome. The tech- nique would seem ideally suited for small benign adrenal tumours, such as Conn’s tumours.
1.
2.
3.
4.
5.
6.
7.
REFERENCES Fahey TJ, Reeve TS and Delbridge L. Adrenalectomy: Expanded indications for the extraperitoneal approach. Aust. N.Z. J. Surg. 1994; 64: 494-491. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalec- tomy in Cushing’s syndrome and phaeochromocytoma. New Engl. J. Med. 1992; 327: 1033. Sardi A, McKmon W. Laparoscopic adrenalectomy for primary aldosteronism (Letter). JAMA 1993; 269 989-90. Higashihara E, Tanaka Y, Harie S et al. Laparoscopic adrenalectomy: The initial 3 cases. J. Urol. 1993; 149:
Femandez-Cruz L, Benarrock G, Torres E el al. Laparos- copic removal of an adrenocortical adenoma. Br. J. Surg. 1993; 80: 874. Gaur DD. Laparoscopic operative retroperitoneoscopy: Use of a new device. J. Urol. 1992; 148: 1137-9. Gaur DD, Agarwal DK, Purohit KC. Retroperitoneal lapa- roscopic nephrectomy: Initial case report. J. Urol. 1993;
