Laparoscopic Adrenalectomy:

A General Overview

By Taylor Baldwin

The University of Kentucky Minimally

Invasive Surgery Lab

Adrenalectomy: Overview

Patient History, Work-up, and Diagnosis

The Laparoscopic Method

The Operating Room

Equipment

The Procedure

Complications and Post Operative Care

Patient History

A 54 year old male presents with the following symptoms:An episodic headacheExcessive sweatingTachycardiaHypertensionAnxietyWeight-lossElevated blood pressure

Workup

Initial symptoms fit the classic model of pheochromocytoma

A CT scan indicates a small (3cm) mass on the left adrenal gland.

Further biochemcial testing reveals elevated metanephrines (metabolite of catecholamines) in the urine, indicating an over secretion of catecholamines in the medulla of the adrenal gland.

This evidence leads to a strong indication of pheochromocytoma in the left adrenal gland.

Possible Methods for Treatment

Surgery (either open or laparoscopically) is the clear first choice treatment of these patients.

A combination alpha/beta blocker can be used to treat patients in an attempt to slow the heart rate. This treatment is often used with surgery as a preoperative treatment to prevent intraoperative hypertension.

Ultimately, the tumor needs to be removed.

Indications for the Laparoscopic Method

Functional adrenal cortical massesCortisol-secreting adenoma (Cushing’s adenoma)Aldosterone-secreting adenoma (Conn’s disease)Adrenal cortical hyperplasia (Cushing’s disease)

Functional adrenal medullary massesPheochromocytomas (tumor of medulla of adrenal

gland)

Nonfunctional adrenal tumorsAdenoma (“incedentalomas”)

Contraindications for the Laparoscopic Method

Adrenal Carcinoma

Adrenal masses greater than 10 cm

Untreated Coagulopathies

Surgeon Inexperience

Surgical history of kidney or liver Increase risk of adhesions making transperitoneal

approach impossibleMake for much riskier dissections

Advantages of the Laparoscopic Method

Reduced wound morbidity

Shorter hospital stay

Easier/quicker return to normal activity

Reduced postoperative pain Due to absence of large surgical wounds

Magnified view of operative field

Less blood loss

Open vs Laparoscopic Adrenalectomy

Open Laparoscopic

Operation Time 4 hours 3 hours

Reoperation Frequency

4.8% 1.4%

Length of Stay 9.4 Days 4.1 Days

Morbidity Rates (30 day)

17.4% 3.6%

Based on a 2004 study:http://linkinghub.elsevier.com/retrieve/pii/S1072751508000707

Patient Positioning

The patient is placed on the operating table slightly flexed at the waist in the right lateral decubitus position.

A cushion can be used under the lumber fossa on the contralateral side to open the operative field and help with trocar placement.

Team Placement

The primary surgeon stands facing the abdominal side of the patient

The second surgeon will also be standing on the abdominal side of the patient

The assisting nurse stands on the opposite side of the patient, facing the surgeon

The anesthesiologist/anesthesia tech typically stands at the head of the operating table on the side of the assistant

Team Placement (Continued)

Primary Surgeon

Assisting Surgeon

Anesthesiologist/ Anesthesia tech

Assisting Nurse

Equipment Placement

The operating room is centered around the operating table

The anesthetic equipment is typically placed at the head of the operating table

Monitors are set up on either side of the operating table for easy viewing

The instrument table is placed at the foot of the bed for easy access by the assisting nurse

Electrocautery and laparoscopic unit are placed where there is room

Equipment Placement (continued)

Anesthetic equipment and monitor for viewing vital signs

Instrument table placed at foot of bed

Electrocautery and laparoscopic unit typically placed in these locations

Monitor used by assistants to view surgery

Monitor used by surgeons to operate

Instruments Used

Laparoscope Typically a 30 degree

laparoscope is used for this procedure

Dissectors 5mm or 10mm grasper Maryland Dissecting

grasper

Cutting Devices Laparoscopic scissors Harmonic Scalpel Hook Cautery

Other Instruments Suction-irrigation Device Extraction Bag Clip Applier

Port Placement

The left adrenalectomy is an operation that requires three 10mm trocars and an optional fourth 5mm trocar

1. The 1st 10mm trocar is placed 2cm below and parallel to the costal margin

2. The 2nd 10mm trocar is placed under the 11th rib at the mid axillary line

3. The 3rd 10mm trocar is placed along the mid-clavicular line, lateral to the rectus muscle

4. The optional 5mm trocar is placed dorsally at the costovertebral angle

Port Placement (continued)

5mm trocar at the costovertebral angle

10mm trocar parallel to costal margin

10mm trocar on the midaxillary line

10mm trocar along midclavicular line

Procedure: Overview Mobilize the colon

Divide the lienophrenic ligament

Divide the splenorenal ligament

Locate, clip, and cut the adrenal vein

Dissect the Lower aspect of the gland

Locate, clip, and cut the Inferior Adrenal Artery

Locate, clip, and cut the Middle Adrenal Artery

Locate, clip, and cut the Superior Adrenal Artery

Dissect the superior, posterior, and lateral aspects of the gland

Remove the Gland through an extraction bag

Procedure

Mobilization of the colonThis is done by cutting the

lienocolic ligamentThis will open the operating

field and help to protect the colon from injury

Mobilization of the SpleenThis is achieved by dividing

the lienophrenic ligamentThis allows the surgeon to

move the spleen and start to access the adrenal vein

Procedure

Division of the Splenorenal ligament This is the ligament that is

holding the spleen and kidney in close proximity

By removing this ligament, the surgeon is able to enter the proper field to find the adrenal vein

Locate, clip, and cut the Adrenal Vein Once located, the surgeon

should trace it back to the renal vein

Depending on the size of the vein, typically 3 clips are used proximally and 2 are used distally

Procedure

Dissect the lower aspect of the gland Once the adrenal vein is

removed, the lower aspect of the gland can be dissected

It is important to carefully watch for the inferior adrenal artery

Locate, clip, and cut the inferior adrenal artery Once this artery is cut, it is

possible to detach the inferior portion of the gland from the kidney

Procedure

Locate, clip, and cut the middle adrenal artery Once this artery is cut it is

possible to dissect the more medial aspects of the gland

Use the appropriate number of clips depending on the size of the artery

Locate, clip, and cut the superior adrenal artery Once this artery is cut it is

possible to dissect the more superior aspects of the gland

Again, use as many clips as necessary

Procedure

Dissect the superior, posterior, and lateral aspects of the glandNow that the gland has

been detached of its veins and arteries, it is possible to dissect it completely

Remove the gland with an extraction bag It is important to watch

out for and not harm other organs during this process

Possible Complications

Hemorrhage

Cause and Prevention Correct any preoperative coagulopathies Clip proximal portions of veins at least twice

Recognition and Management Intraoperative hemorrhage identified by excessive

bleeding and may require conversion to an open operation if hemostasis is not achieved

Postoperative hemorrhage is identified by monitoring vital signs and urine output overnight

Possible Complications (Cont.)

Damage to intraabdominal or retroperitoneal structures

Cause and Prevention Knowledge of anatomy is key! Trace veins to point of origin to be sure Always know the location of spleen, liver, and pancreas

Recognition and Management Damage to liver or spleen usually results in intraoperative

or postoperative bleeding Damage to pancreas can result in pancreatitis Often these complications are self managed, but

sometimes may require medical or surgical management

Post Operative Care

Pain medication given as required (typically only necessary for a few days)

Patient is allowed and able to ambulate (move about) on the same day

Liquid food intake is started the night of the procedure

Solid food intake may begin on the first postoperative day

The patient can leave the hospital on the second or third postoperative day