Several laparoscopic approaches to the adrenal glands are recognized, including the following:
1. Transabdominal lateral—with the patient in the lateral decubitus position
2. Transabdominal anterior—with the patient in the supine position
3. Retroperitoneal endoscopic adrenalectomy—lateral or posterior
Although the retroperitoneal approach is advocated by some authors,14"17 the technique of choice by most surgeons performing laparoscopic adrenalectomy is the transabdominal lateral approach, originally described by us in 1992.118 Positioning of the patient in the lateral decubitus position uses gravity to help retract the surrounding organs (including the bowel), and effectively exposes the adrenal gland for laparoscopic intervention. As a result, there is reduced dissection and minimal retraction of the vena cava and other adjacent structures.
Herein, the details of our originally described transabdominal lateral approach are followed by short comments on other techniques. The patient is positioned to maximize the distance between the costal margin and the iliac crest. This is achieved by adjusting the operating table in the jackknife position, with the patient placed in the lateral decubitus position with the operated side up. Sufficient padding is placed over pressure points and the patient is strapped and taped in position. The surgical prep should extend from the nipple to the anterosuperior iliac spine, and from the midline anteriorly to the spine posteriorly. This allows for conversion to an open procedure should this be necessary.
Patients are placed in the lateral decubitus position with the left side up. The surgeon and the assistant stand on the side opposite the diseased gland (Fig. 74-1). A flank cushion is positioned under the patient's right side and the table is flexed so that the left side is hyperextended (Fig. 74-2). The left arm is extended and suspended. The surgical area is prepared as previously described. An open technique is used to access the abdominal cavity in the left subcostal area at the level of anterior axillary line, and carbon dioxide, up to 15 mm Hg of pressure, is insufflated. One 10-mm trocar is then inserted into this site, and a 30-degree, 10-mm laparoscope is introduced, through which the abdominal cavity is explored. If the inspection is satisfactory, two more 5- or 10-mm trocars are inserted under direct vision into the flank, depending on available instrumentation: one under the 11th rib and one slightly more anteriorly and medially to the first trocar. Occasionally, a fourth trocar is needed for retraction and is inserted at the costovertebral junction dorsally (see Fig. 74-2). All trocars should be at least 5 cm and, more optimally, 8 to 10 cm apart. The laparoscope is then inserted in the most anterior trocar and the surgeon works with a two-hand technique through the other two trocars. Working with the laparoscopic scissors with cautery or the ultrasonic scalpel in the right hand and a curved dissector in the left hand, the surgeon mobilizes the splenic flexure medially to
FIGURE 74-1. Laparoscopic left adrenalectomy: operating room layout.
FIGURE 74-1. Laparoscopic left adrenalectomy: operating room layout.
move the colon from the inferior pole of the adrenal and expose the lienorenal ligament (Fig. 74-3). This mobilization allows instruments to be inserted more easily and helps prevent inadvertent trauma to the colon or spleen during instrument insertion. Then, the lienorenal ligament is incised inferosuperiorly approximately 1 cm from the spleen (Fig. 74-4). The dissection is carried up to the diaphragm and stopped when the short gastric vessels are encountered posteriorly behind the stomach. This maneuver allows the spleen to fall medially, thus exposing the retroperitoneal space (Fig. 74-5). The lateral edge and anterior portion of the adrenal gland become visible in the perinephric fat superiorly and medially. If necessary, a fourth 5-mm trocar is inserted dorsally at the costovertebral angle to gently retract large-sized spleens and open the space or to push the left kidney or the surrounding fat downward to better expose the inferior pole and lateral edge of the adrenal gland. This trocar should always be inserted after the previous three because the splenorenal ligament must be opened first, so the trocar can pass over the lateral and superior borders of the kidney. This port, however, is usually not necessary in patients with a normal-sized spleen. Laparoscopic ultrasound may be used as an adjunct to identify the adrenal gland, the mass within the gland, and the adrenal vein.3 The dissection of the adrenal gland can be easy or difficult, depending on the type of perinephric fat that is present. Two types of fat are encountered: (1) the soft, nonadherent, areolar fat that is easy to dissect; and (2) dense, adherent fat that contains multiple small
veins originating from the retroperitoneum. To avoid fracture of the adrenal capsule, it is helpful to leave a little peri-adrenal fat on the adrenal, so that this tissue, rather than the adrenal itself, is retracted. Grasping the perinephric fat, the surgeon dissects the lateral and anterior part of the adrenal gland. Hook electrocautery or ultrasonic scalpel is a useful
instrument for this phase of dissection. Once the lateral portion of the adrenal gland has been exposed, the patient is moved to the Fowler's position to permit further downward migration of the bowel loops and the spleen. Any saline irrigation, bleeding, or oozing flows downward away from the area of the dissection. The dissection can be continued either inferiorly, so that the left adrenal vein can be clipped early in the dissection or start superiorly and go down medially to clip the adrenal vein last. The dissection depends on the exposure gained after the spleen has been mobilized, the type of disease, and the size of the adrenal mass. In large adrenals (>5 cm), the left adrenal vein may be difficult to visualize. In such cases, dissecting the lateral and superior adrenal poles first allows better mobilization and makes clipping the adrenal vein easier later during the dissection. In smaller adrenals (<5 cm), it is feasible and easy to dissect and clip the adrenal vein. Most left adrenal veins are about 10 mm in diameter and can be clipped with medium to large
titanium clips placed with a clip applier. With a right-angled dissector, the adrenal vein is dissected from its insertion into the left adrenal gland. It is not necessary to identify and dissect the origin of the vein from the left renal vein. The adrenal vein is clipped about 1 cm from the renal vein: two clips are placed proximally to the gland and two are positioned distally (Fig. 74-6). The vein is then divided with laparoscopic straight scissors. At this point, adrenal mobilization becomes easy. It is grasped on the perinephric fat with the left-hand grasper and pushed upward and laterally to permit dissection of the medial and superior portions. This dissection is accomplished with hook cautery or ultrasonic scalpel. The inferior phrenic arterial branches often require ligation as they approach the superior pole of the left adrenal gland. Once the adrenal gland is free, hemostasis is verified by repeated irrigation and aspiration. The gland is then extracted in total after it is placed in an appropriately sized impermeable nylon bag. The bag is removed through the most anterior trocar by spreading the abdominal wall musculature using a Kelly clamp. The incision may have to be enlarged to remove large specimens (>4 to 5 cm) without rupturing the bag. Drainage is seldom necessary unless pancreatic injury is suspected. All fascial incisions are closed with 2-0 absorbable sutures, and skin incisions are closed with 4-0 subcuticular absorbable sutures.
Patients are positioned in the lateral decubitus position with their right side up. Pneumoperitoneum is established in the same way as for left adrenalectomy. An open technique is used to access the abdominal cavity approximately 2 cm below and parallel to the costal margin. A 10-mm trocar is inserted at this site for the 30-degree angled laparoscope. Inspection of the abdominal cavity is carried out. Under direct vision, three additional 10-mm trocars are inserted 2 cm below and parallel to the costal margin. The second trocar is positioned in the right flank, inferior and posterior to the tip of the 11th rib just above the hepatic flexure of the colon, which seldom needs to be mobilized. The third trocar is then inserted into the most anterior position of the subcostal area between the epigastrium and the anterior axillary line. This most medial trocar should be lateral to the edge of the ipsilat-eral rectus muscle.
The last trocar is introduced at the costovertebral subcostal angle after the peritoneal reflection of the lateral edge of the right kidney has been dissected to avoid injury to the right kidney. Four trocars are necessary because the right lobe of the liver must be retracted to expose the most medial aspect of the right adrenal gland (Fig. 74-7). It is, therefore, crucial that the liver retractor be inserted under direct vision, through the most anterior port, so that the right hepatic lobe can be lifted and pushed anteromedially. The laparoscope is removed from the first placed trocar and inserted in the second one, and the surgeon works with the two most lateral trocars. The camera can also be positioned dorsally, and the surgeon works with the two trocars in the middle to obtain another view of the dissection field. This is especially useful for dissecting the superior aspect of the adrenal gland. The liver often must be mobilized to obtain the best exposure of the junction between the adrenal gland and the inferior vena cava (Fig. 74-8). The right lateral hepatic attachments and the triangular ligament are therefore dissected from the diaphragm using laparoscopic scissors or an ultrasonic scalpel. This dissection permits more effective retraction to push the liver medially using a fan or some other atraumatic retractor. This is the key for providing adequate exposure of the right adrenal vein and its entry into the vena cava. We prefer to create a right-angled plane between the anterior aspect of the right kidney and lateral portion of the liver. This plane provides enough space to work and adequate exposure in case of bleeding. Laparoscopic ultrasound may
Inferior vena cava
FIGURE 74-8. Upper, Mobilization of the right lobe of the liver. Lower, Dissection and control of the right adrenal vessels.
Inferior vena cava
FIGURE 74-8. Upper, Mobilization of the right lobe of the liver. Lower, Dissection and control of the right adrenal vessels.
be of assistance in identifying the anatomy. The right gland is dissected next. If the mass is smaller than 4 cm in diameter, gaining access to the right adrenal vein initially is possible, which permits easier dissection of the rest of the adrenal gland. The inferolateral edge is mobilized, and dissection is continued medially and upward, along the lateral edge of the vena cava. The adrenal vein should be seen at this stage. This vein is often short and sometimes broad. Usually, the vein can be clipped with medium to large titanium clips, and at least two should be applied at the vena cava side (see Fig. 74-8). If there is not enough space for clips, then a vascular cartridge of a 30- or 35-mm laparoscopic stapler is used for secure division of the right adrenal vein. Smaller veins may be encountered superiorly; these should be clipped or cauterized to prevent bleeding. The superior pole of the gland is dissected next, and small branches from the inferior phrenic vessels can be clipped or cauterized with a hook cautery or ultrasonic scalpel. Again, a Fowler's position permits all fluids to migrate downward. The lateral border of the gland is then dissected from the perinephric fat using the same instruments. Meticulous dissection close to the gland prevents tearing of the lateral branches of the vena cava and other vessels from the retroperitoneum. If a large mass is encountered, we prefer to dissect laterally and superiorly first and then move down along the vena cava to reach the adrenal vein. Once the mass has been dissected free, it is placed in impermeable nylon bag and removed through the most anterior trocar site. All wounds are closed as described for the left side. The fascia of the fourth (dorsal) trocar site is not closed because of the depth of this wound.
The retroperitoneal endoscopic approach has been advocated by a few laparoscopic surgeons.14'17 The main advantage of this approach is that adrenal resection can be performed in a patient with intra-abdominal adhesions due to previous surgery. In our experience, it is rare that conversion to open procedure is required due to adhesions.3 Another theoretical benefit of this approach is decreased physiologic impact on the cardiovascular and respiratory systems. However, the initial concerns over hypercarbia and other hypothetical detrimental effects were not supported in a study comparing both approaches.14 The main drawback is the quite small operative field, usually restricting this approach to small glands of less than 5 to 6 cm in diameter. This limited field and exposure can also be a major disadvantage in case of vascular injury, making control and repair more difficult than in the transabdominal approach. Other disadvantages include the lack of anatomic landmarks and the inability to explore the abdominal cavity, particularly the liver. The retroperitoneal approach can be performed in two ways.
Lateral Decubitus Approach. The positioning of the patient is the same as for the lateral transabdominal approach. Creation of the retroperitoneal space is commonly done with disposable dissection balloons, and the peritoneal sac should be mobilized to prevent perforation of the peritoneum and injury to viscera. The trocars are inserted after creation of the space and are close to the costal margin.
Prone Jackknife Approach. This approach is essentially the same as the former one, except for the positioning of the patient. The patient is placed in the prone position, with moderately flexed hips and the arms extended cephalad. The advantage of this technique is that it is not necessary to change the patient position for bilateral exploration, theoretically allowing a shorter operative time. However, rapid conversion to open surgery for bleeding is difficult in this position.
The transabdominal anterior laparoscopic approach can be a lengthy procedure owing to the difficult dissection of the splenic flexure, spleen, and the pancreatic tail on the left side and the duodenum on the right. In addition, on the right side, the adrenal vein, found posteriorly to the vena cava, is difficult to dissect and control. Although in bilateral adrenalectomy it is not necessary to change the position of the patient, the average operating time is similar to the lateral transabdominal approach. Because of its drawbacks, most surgeons have abandoned this approach.
Bilateral Laparoscopic Adrenalectomy
The indications for bilateral laparoscopic adrenalectomy include the following19:
1. Cushing's disease refractory to transsphenoidal pituitary resection and/or irradiation
2. Cushing's syndrome due to ACTH-independent macronodular or micronodular adrenal hyperplasia
3. Ectopic ACTH syndrome, when the primary tumor cannot be resected or medical treatment has failed
4. Conn's syndrome caused by bilateral adrenal adenomas
Other less prevalent relative and possible indications include (1) unilateral pheochromocytoma in multiple endocrine neoplasia (MEN) type 2A, due to the fact that in 50% of cases a metachronous lesion develop in the contralateral side within 10 years of resection of the affected side20; (2) idiopathic hyperaldosteronism caused by bilateral symmetrical adrenal hyperplasia refractory to medical treatment; and (3) congenital bilateral adrenal hyperplasia, which is difficult to manage medically.19
There are several possible surgical approaches for bilateral laparoscopic adrenalectomy.
Transabdominal Lateral Approach. The transabdominal lateral approach is the preferred approach in our opinion.
The patient is placed in the lateral decubitus position; usually the left side is operated first because it is easier. After all trocar sites are closed, the patient is repositioned and redraped to expose the right side. A 15- to 20-minute turnover time is necessary, not significantly adding to the operative time.2 We prefer this bilateral approach, because gravity aids the dissection when the patient is in the lateral decubitus position and it offers a wide operative field and better control of blood vessels. Furthermore, it may be safer than the retroperitoneal approach for the right adrenal, where a better control of a possible major vascular injury (i.e., vena cava) is needed. We have successfully performed bilateral laparoscopic adrenalectomy within a reasonable period using a bilateral lateral technique.3 Using this approach, Chapuis and associates,21 with the largest published series on bilateral laparoscopic adrenalectomy in 24 patients with Cushing's syndrome, reported no major postoperative complications. The operative lengths have ranged from 243 to 386 minutes for the reported bilateral procedures using this approach.
Retroperitoneal Approach. This can be accomplished using the lateral or the posterior methods described earlier. The few series with data on bilateral laparoscopic lateral and posterior retroperitoneal approaches have not shown greater hypercarbia than with the lateral transabdominal approach.22 24
Anterior Approach. Despite its theoretical advantage in bilateral adrenalectomy, the drawbacks regarding difficulty in exposure and dissection have led most surgeons to abandon this approach.
No randomized, prospective studies have been conducted to compare laparoscopic bilateral adrenalectomy with open bilateral surgery. However, the available literature on bilateral laparoscopic adrenalectomy is encouraging, with low morbidity and mortality rates.1'3'21'22,25'26 In the setting of Cushing's syndrome, the morbidity and mortality rates of the laparoscopic approach are noticeably lower than for open surgery.1'3 2122 The typical operative length for bilateral laparoscopic adrenalectomy, including all approaches, is approximately 300 minutes.19 There have been some reports of operative times longer than 300 minutes with cases of hypercarbia requiring hyperventilation but without significant sequelae.22'24 Fernandez-Cruz and colleagues27'28 have recommended helium pneumoperitoneum for the bilateral laparotomy procedure to prevent carbon dioxide retention and acidosis. The use of helium is strongly recommended by this group, especially in patients with pheochromocytoma with previous cardiovascular or respiratory disorders.28
Possible indications for adrenal-sparing surgery include bilateral pheochromocytoma and well-circumscribed bilateral Cortisol or aldosterone-producing adenomas. The purpose is to avoid life-long Cortisol replacement therapy.29 The operative technique involves basically the same initial steps as for total adrenalectomy. After exposing the adrenal glands, dissection is first performed at the inferior borders and then carried upward along the lateral aspect using a hook cautery or ultrasonic scalpel and a gentle grasping forceps. Ultrasound of the gland is then performed using a flexible 7.5-MHz, 10-mm diameter probe to demonstrate the location of the adrenal vein and the arterial supply and to confirm the location and borders of the adrenal lesion. At this stage, the adrenal lesion can be easily dissected free and elevated. While concomitantly displaying the margins of the tumor with the ultrasound, the harmonic shears are used to blood-lessly transect the adrenal gland away from the lesion. The excised specimen is then placed in a bag, retrieved, and sent for immediate histopathologic examination to confirm histology and assess the margins. At least a 5-mm rim of normal adrenal tissue is preferred.
The availability of 2-mm instrumentation and camera technology has triggered the emergence of needlescopic surgery. The rationale behind this technique is to further minimize the abdominal wall trauma, and hence speed the convalescence and improve cosmesis. The positioning of the patient and the number of trocars are similar to the traditional laparoscopic adrenalectomy. A 10 to 12-mm trocar is inserted into the superior aspect of the umbilicus to accommodate the 10-mm angled scope, under which most of the procedure is conducted. It also enables the use of larger instruments should they be required (e.g., vascular endostapler) and the retrieval of the specimen. During these steps, the procedure is monitored through the 2-mm needlescope. In the left side, two additional trocars of 2- and 5-mm are used, and in the right side, a fourth 2-mm trocar is used for liver retraction. Placement of the 2-mm ports does not require skin incisions. These ports can be readily inserted through a needle-like puncture. Thus, at the end of the procedure, these miniature puncture sites require no skin closure, except for Steristrips. The 5-mm port is used by the surgeon's dominant hand to accommodate larger instruments such as scissors, electrocautery, suction-irrigation devices, and clip appliers. Dissection is carried out using 2-mm graspers, scissors, and hook electrocautery, and vascular control is achieved with electrocautery (unipolar or bipolar) and a 5-mm clip applier.
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