Results

TT approach for adrenalectomy may represent a unique minimally invasive option for the rare patient with adrenal pathology and concomitant scarring of the intraperi-toneal and retroperitoneal spaces due to prior transperitoneal and retroperitoneal

TABLE2 ■ Thoracoscopic Transdiaphragmatic Adrenalectomy: Clinical Experience

Case 1

Case 2

Case 3

Operation date

12/9/99

4/13/00

6/8/00

Sex/age (yr)

Male/62

Male/64

Female/20

Body mass index

21.4

40

20

American Society of

3

3

3

Anesthesiologists class

Prior abdominal surgery

R radical nephrectomy,

L radical nephrectomy,

Bilateral nephrectomy

L Adrenalectomy

R partial nephrectomy,

cholecystectomy,

appendectomy

Adrenal side

R

R

L

Adrenal size (cm)

3.5

2.4

2.8

Patient position

Prone

Prone

Prone

No. of ports

4

4

4

Blood loss (cc)

150

500

50

Total surgical time (hr)

4.5

6.5

2.5

Diaphragm suturing time (min)

25

28

18

Inadvertent celiotomy

None

None

None

Intraop. intravenous fluids (cc)

3300

4000

1500

Pulse rate/min

Maximum

120

136

112

Minimum

76

70

54

Blood pressure

Maximum

180/90

180/100

190/100

Minimum

120/60

108/64

90/50

End tidal carbon dioxide (mmHg)

Maximum

36

40

39

Minimum

25

33

28

Chest tube

Yes, overnight

Yes, overnight

No

Resume ambulation (days)

1

1

1

Resume oral intake (days)

1

1

1

Morphine sulfate analgesia (mg)

18

24

38

Hospital stay (days)

2

2

2

Convalescence (wk)

4

4

8

Postop. diaphragm mobility

N/A

Normal

Normal

Adrenal wt. (g)

12

17

12

Pathologic diagnosis

Metastatic renal

Metastatic renal

Myelolipoma

cell carcinoma

cell carcinoma

Complications

None

None

None

Followup (mo)

8

4

2

aMovement of the postoperative hemidiaphragm was evaluated by fluoroscopic examination of the chest. Abbreviations: R, right; L, left. Source: From Ref. 16.

Freehand laparoscopic suturing and intracorporeal knot tying techniques allowed satisfactory airtight suture repair of the diaphragmatic incision in all three cases.

open surgery. In such cases, transabdominal laparoscopic adrenalectomy may be a technically difficult undertaking, and the virgin thoracic cavity may represent a reasonable access route to the pathological adrenal gland.

Table 2 shows demographic, intraoperative and postoperative data of the three clinical cases performed at the author's institution (16).

A considerable history of prior transperitoneal and retroperitoneal open surgery was present in all three patients. The initial two cases required a long operating time of 4.5 and 6.5 hours, respectively. However, the third case was completed in 2.5 hours. Blood loss of 150 and 500 cc in the first two cases, respectively decreased to 50 cc in the third case due to increasing confidence with the novel approach. Histology revealed solitary adrenal metastasis in the initial two cases and adrenal myelolipoma in the third case. Malignant adrenal disease and its periadrenal reaction and neovascularity may explain the high intraoperative blood loss in the first two cases.

Freehand laparoscopic suturing and intracorporeal knot tying techniques allowed satisfactory airtight suture repair of the diaphragmatic incision in all three cases.

As a result, the authors deemed a chest tube not necessary in the third case (Fig. 7). No clinically significant changes of hemodynamic and capnometric parameters occurred in any case. Postoperatively, the patients were offered fluoroscopic examination of the chest and in the two patients who consented to undergo the test, normal respiratory excursions of the ipsilateral hemidiaphragm were documented. No late complications occurred at a mean follow-up of seven months, and follow-up computerized tomography showed no local recurrence in the adrenal bed in the two patients with adrenal malignancy. A total of five patients have undergone transthoracic transdiaphragmatic adrenalectomy at the Cleveland Clinic from December 1999 to date.

FIGURE 7 ■ Postoperative X-ray of case 3. (See Table 2 and text for details.) Source: From Ref. 16.

FIGURE 7 ■ Postoperative X-ray of case 3. (See Table 2 and text for details.) Source: From Ref. 16.

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