Open Operative Approaches to the Adrenal Gland

Roderick M. Quiros, MD ■ Scott M. Wilhelm, MD ■ Richard A. Prinz, MD

Adrenal diseases demand a thorough understanding of both endocrine physiology and surgical anatomy. Although they are rare entities, advances in computed tomography (CT) and other imaging modalities have increased detection of adrenal abnormalities that require evaluation to determine if surgical intervention is needed.

Several open approaches have been used for adrenalectomy. The transperitoneal approach was first performed by Thornton in 1889 to remove a 20-pound adrenal tumor with the left kidney in a 36-year-old woman.1 The flank approach described by Mayo in 1927 was used to resect a pheochro-mocytoma.2 The posterior approach was reported by Young in 1936.3

Each of these approaches has advantages and disadvantages. The appropriate choice can be made only after weighing a number of factors, such as the nature of the disease (including the possibility of malignancy) and the patient's condition, habitus, and anatomy. Other considerations include the presence of unilateral or bilateral disease and the surgeon's familiarity with the various approaches.

Recently, laparoscopy has been used for the surgical treatment of adrenal disease. Since the early reports of this technique, laparoscopy has become the method of choice for removing many adrenal lesions.4 6 Most surgically treatable adrenal masses are unilateral and/or benign, making them ideal for laparoscopic surgery. The operative principles that underpin the laparoscopic approach, such as familiarity with retroperitoneal anatomy, are identical to those for the open approaches. There are, however, several indications when open adrenalectomy is still warranted.

1. An adrenal mass with preoperative suggestion of malignancy as noted by invasion of surrounding structures, associated lymphadenopathy, or venous extension of the tumor into the renal vein or inferior vena cava (IVC) should be resected through an open approach.

2. Evidence of local invasion found during laparoscopic adrenalectomy should prompt conversion to an open procedure to facilitate a definitive en bloc resection.

3. Bleeding that cannot be controlled during a laparoscopic adrenalectomy, most commonly from an adrenal vein laceration, requires conversion to an open adrenalectomy. This problem happens more frequently during dissection of the right adrenal vein because it is very short and has a posterior lateral insertion into the IVC. This type of bleeding can be extremely difficult to control laparoscopically, and prompt conversion may be lifesaving.

4. Recurrence of a previously resected adrenal mass necessitates an open adrenalectomy. This is most often encountered with malignant pheochromocytomas or adrenocortical carcinomas. Re-excision is best performed by an open approach because of the scarring and loss of tissue planes after the initial operation.

5. With virilizing adrenal tumors, an open approach should be seriously considered, because 70% to 85% of these rare tumors are actually functional adrenocortical carcinomas.7'8 In light of the extremely high rate of malignancy, we would be cautious and not recommend a laparoscopic approach.

6. Finally, tumor size must be considered. Lesions above 6 cm have a greater risk of malignancy. Even for lesions that are certainly benign, size greater than 8 to 10 cm may be a relative indication for an open adrenalectomy, especially for surgeons without substantial knowledge of retroperitoneal anatomy and advanced laparoscopic skills.9

This chapter reviews the surgical anatomy of the adrenal glands and describes the four primary open approaches— anterior, thoracoabdominal/lateral transthoracic, posterior, and flank—used to expose the adrenal glands.

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