Operative Technique Laparoscopic Approach

Since the publication of the last edition of this text, a dramatic and exciting change in the overall approach to adrenalectomy has occurred. Whereas previously only a limited number of laparoscopic adrenalectomies had been reported in total,32 some involving significant bleeding33 and a few including removal of pheochromocytomas,32 34 laparoscopic adrenalectomy has become the accepted standard method, even to remove pheochromocytomas. Multiple advantages of the laparoscopic approach have been demonstrated, including reduced pain, smaller incisions, more rapid recovery both in hospital and after dismissal, and fewer complications.35 37

Using a lateral decubitus position, a pneumoperitoneum is established and three or four trocars are placed coursing around beneath the costal margin toward the flank. On the right, the triangular ligament is dissected and the liver is retracted medially. On the left, the spleen and pancreas are mobilized and, by gravity, fall anteriorly and medially, thereby exposing the left adrenal area. On either side, methodical, careful dissection and controlling of all vessels are critical to success. Placing the pheochromocytoma into a bag facilitates extraction of the tumor, and it is withdrawn through one of the larger trocar sites, which may need to be enlarged somewhat. Improvements in the optics of the camera, the use of a harmonic scalpel, and refinements to the instrumentation have further enhanced this approach.

Relatively few studies have been devoted to laparoscopic adrenalectomy specifically of pheochromocytoma. Cheah and coworkers38 published a series of 39 laparoscopic adrenalectomies for pheochromocytoma, only 1 required hand assistance for a 15-cm tumor. The postoperative hospitalization was limited to 1 to 2 days, facilitated by adequate preoperative preparation and definitive localization studies in addition to the laparoscopic approach. In three series,39"41 a 20% to 23% major complication rate was reported for laparoscopic adrenalectomy for pheochromocytoma, but this is the exception in most published series. Comparing 22 patients with pheochromocytoma evenly divided between laparoscopic and conventional anterior adrenalectomy, Inabnet and coauthors29 found no clinically important differences in intraoperative hemodynamic parameters between the two groups.

The surgical experience with pheochromocytomas at the Mayo Clinic during the era of laparoscopic adrenalectomy started in October 1995. A total of 131 pheochromocytomas were operated from October 1995 through April 2004, including 86 (66%) laparoscopic adrenalectomies, 7 (5%) that were converted from laparoscopic to open, 35 (27%) performed as an open anterior approach, and 1 (1%) each utilizing a posterior approach and a hand-assisted laparoscopic approach. One patient had the operation aborted because of extreme hypertension with induction of anesthesia; the patient was more aggressively prepared with additional a-blocking medication and subsequently underwent successful laparoscopic adrenalectomy. This single-disease experience is extracted from 393 laparoscopic adrenalectomies on 345 patients from 1993 through April 2004. The mean operative time for the laparoscopic patients was 141 minutes (range, 48 to 324 minutes) and mean hospital stay was 2.6 days, which compare favorably with 216 minutes and 3.1 days reported by Brunt and colleagues.42 These pheochromocytoma patients included six (5%) with MEN 2A, four (3%) each with MEN 2B and von Hippel-Lindau (VHL) syndrome, and three with neurofibromatosis.

Phenoxybenzamine (Dibenzyline) was the medication used in 94% of patients for preoperative a-adrenergic blockade, extending for an average of 15 days (range, 2 to 40 days). Despite this preparation, 69% of patients developed either hypertensive or hypotensive episodes intraoperatively, for which they were given intravenous medication. The mean maximum and minimum systolic blood pressures were 192 (peak, 310) and 83 mm Hg (lowest, 31), respectively. However, no patient had a complication related to these episodes. A single patient died postoperatively because of a bowel perforation unrelated to the adrenalectomy. No patient has suffered recurrent or metastatic disease, including peritoneal or port site contamination.43 Nearly 40% of these tumors were discovered as "incidentalomas" in an abdominal imaging study obtained for unrelated reasons. The open anterior approach was utilized in patients who were undergoing other open abdominal operations, patients with tumors larger than approximately 8 cm, or at times when a partial adrenalectomy was elected in patients with some form of familial disease.

The principles for excision of pheochromocytomas irrespective of surgical method include complete removal with the tumor intact, minimizing wide blood pressure fluctuations. Laparoscopic adrenalectomy for pheochromocytoma is a challenging technique that should be undertaken only by experienced laparascopists who also have knowledge and operative experience in managing adrenal disorders.

Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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