Introduction And Background

Laparoscopic adrenalectomy was initially performed, in 1991, for a case of adrenal hematoma (1). Gagner et al. first reported the procedure for neoplasia in October 1992 (2); however, Go et al. had begun a series of laparoscopic adrenalectomies in patients with primary aldosteronism in January 1992 (3), followed by Suzuki et al., who had also commenced a series in February the same year (4).

Laparoscopic adrenalectomy has become the standard surgical approach for most surgically correctable benign disorders of the adrenal gland.

No randomized controlled trials have been undertaken to compare laparoscopic adrenalectomy with traditional open surgery. However, on the basis of comparative studies, laparoscopic adrenalectomy has demonstrated superiority in terms of analgesic requirements, recovery, convalescence, length of stay, and cosmesis, whilst maintaining equivalent long-term operative efficacy (5-8).

Laparoscopic approaches to the adrenal gland may be performed via either transperitoneal or retroperitoneal routes and may be either unilateral or bilateral. Initially, the transperitoneal route was used, predominantly because of the familiarity of this approach with open surgery (9,10). However, following the development of retroperitoneal techniques by Gaur in 1992, lateral and posterior retroperitoneal approaches have also been adopted (11).

Further modifications have since been developed including the transthoracic approach (12), the supragastric approach for left-sided lesions (13,14), hand-assisted laparoscopic adrenalectomy (15), the use of needlescopic instruments (16,17), and, most recently, robotic laparoscopic adrenalectomy (18-20).

This chapter will describe the authors' preferred approach of transperitoneal laparoscopic adrenalectomy and also provide a review of the alternative methods that have been described.

TABLE 1 ■ Indications for Laparoscopic Adrenalectomy

Functioning lesions

Aldosteronoma

Adreno corticotrophic hormone-independent Cushing's syndrome

(adenoma and hyperplasia)

Adreno corticotrophic hormone-dependent Cushing's syndrome (pituitary

adenoma refractory to treatment and nonlocalized ectopic adreno

corticotrophic hormone source)

Pheochromocytoma-benign/malignant

Congenital adrenal hyperplasia21

Cortical adenoma

Possible malignancy

Primary adrenal carcinomaa

3-5 cm lesions with suspicious imaging characteristics or progressive

growth on serial imaging

>5 cm lesion

Metastasis'3

Benign symptomatic lesions

Cyst

Myelolipomac

aRole of laparoscopic adrenalectomy controversial.

bRemove if primary controllable or if symptomatic.

laparoscopic adrenalectomy indicated if lesions are greater than 4 cm in size or features suspicious of

malignancy are present.

Unilateral laparoscopic adrenalectomy is the treatment of choice for patients with Cushing's syndrome due to unilateral adrenal adenomas.

After an initial controversy, laparoscopic adrenalectomy for pheochromocytoma is now well accepted as a standard indication for unilateral or bilateral disease.

The quintessential objective during laparoscopic adrenalectomy is early control of the adrenal vein, and in this regard, pheochromocytomas are best suited to the transperitoneal approach.

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