Surgical approaches to adrenalectomy

Surgical Approaches Surgical Approaches to Adrenalectomyto Adrenalectomy

ByBy

Professor DR. Momen AbuShellouProfessor DR. Momen AbuShellouProfessor of General SurgeryProfessor of General Surgery

IntroductionIntroduction• Surgery of the adrenal gland consists of operative procedures to correct

endocrine abnormalities or to treat malignant disease. • Traditional open adrenal surgery has been performed since the late 19th

century. Various techniques and anatomic approaches have been described for adrenalectomy, but the essential surgical principles have remained unchanged for a century. • The introduction of laparoscopic adrenalectomy has revolutionized

adrenal surgery and largely supplanted the open approach. However, we are not yet ready to relegate open adrenal surgery to the history books. There is a diminished but vital role for open adrenal surgery in the management of adrenal disease. • The future of adrenal surgery is evolving. New technology, such as

robotics and percutaneous ablation, is being developed.

Historical BackgroundHistorical Background• 1522: Eustachius discovered the adrenals. He reported his findings in

1563.• 1889: 1st unintended adrenalectomy (removed the adrenal en bloc with the

kidney) performed by Thornton.• 1914: Sargent performed the first planned adrenalectomy.• 1927: Mayo performed the first flank adrenalectomy.• 1936: Young described the posterior approach using a “hockey stick”

incision to access both adrenal glands simultaneously.• 1965: Turner-Warwick developed a supracostal transdiaphragmatic

variation of Young’s posterior approach.• 1991: Gagner performed the first laparoscopic adrenalectomy.• 1997 & 1998:Retroperitoneal access has been developed for both posterior

(Baba et al, 1997) and flank (Gasman et al, 1998) approaches.

Surgical Anatomy: Surgical Anatomy: TopographyTopography

• The adult adrenal glands weigh 4 to 8 g and measure about 4 × 3 × 1 cm. • They are composed of two distinct and highly specialized endocrine tissues, the

cortex and the medulla, which are embryologically, anatomically, biochemically, and pathologically distinct, the cortex and the medulla.

• The adrenal glands lie on the anteromedial surfaces of the kidneys near the superior poles. Both, the adrenal glands and the kidneys are retroperitoneal.

• The adrenal glands differ in shape. The left adrenal gland is more flattened and is in more extensive contact with the kidney. It may extend onto the medial surface of the kidney, almost to the hilum. The right adrenal gland is more pyramidal and lies higher on the kidney. Because of its shape and location, the right adrenal gland is higher than the left adrenal gland.

• The adrenal gland, together with the associated kidney, is enclosed in the renal fascia (of Gerota) and is surrounded by fat. This perirenal fat is more yellow and fi rmer than fat found elsewhere in abdomen.

Surgical Anatomy: Surgical Anatomy: TopographyTopography

Surgical Anatomy: Surgical Anatomy: RelationsRelations

• For the right adrenal gland: the anterior surface is superiorly in contact with the “bare area” of the liver, medially with the inferior vena cava, laterally with the bare area of right lobe of the liver, and inferiorly there is an occasional contact with the first part of the duodenum and rarely the peritoneum. The posterior surface of the right adrenal gland is superiorly in contact with the diaphragm, and inferiorly with the anteromedial aspect of the right kidney.

• For the left adrenal gland: the anterior surface is superiorly in contact with the peritoneum (posterior wall of the omental bursa) and the stomach, and inferiorly with the body of the pancreas. The posterior surface is in contact medially with the left crus of the diaphragm and laterally with the medial aspect of the left kidney.

• The medial borders of the right and left adrenal glands are about 4.5 cm apart. In this space, from right to left, are the inferior vena cava, the right crus of the diaphragm, part of the celiac ganglion, the celiac trunk, the superior mesenteric artery, part of the celiac ganglion, and the left crus of the diaphragm.

Surgical Anatomy: Surgical Anatomy: RelationsRelations

Surgical Anatomy: Blood Surgical Anatomy: Blood SupplySupply

• The arterial supply to the adrenal glands is from three general sources:• A group of six to eight arteries arises separately from the inferior phrenic

arteries. One artery may be larger than the others or all may be of similar size.• A middle adrenal artery arises from the aorta at or near the level of the origin

of the superior mesenteric artery. It may be single, multiple, or absent and may supply only the perirenal fat.

• One or more inferior adrenal arteries arise from the renal artery, an accessory renal artery, or a superior polar renal artery. Small twigs may arise from the upper ureteric artery.

• The adrenal venous drainage does not accompany the arterial supply and is much simpler:• Usually a single vein drains the adrenal gland, emerging at the hilum. • The left adrenal vein passes downward over the anterior surface of the gland

and is joined by the left inferior phrenic vein before entering the left renal vein. • The short right adrenal vein passes obliquely to open into the inferior vena

cava posteriorly. It does not have any tributaries.

Surgical Anatomy: Blood Surgical Anatomy: Blood SupplySupply

Surgical Anatomy: Lymphatic Surgical Anatomy: Lymphatic DrainageDrainage• The lymphatic vessels of the adrenal gland consist of a subcapsular

plexus that drains with the arteries and a medullary plexus that drains with the veins.

• Lymphatic drainage from both adrenal glands is to renal hilar nodes, periaortic nodes, and by way of the diaphragmatic orifices for the splanchnic nerves to nodes of the posterior mediastinum, above the diaphragm.

• Lymphatic vessels from the upper pole of the right adrenal gland may enter the liver.

Surgical Anatomy: Lymphatic Surgical Anatomy: Lymphatic DrainageDrainage

Surgical Anatomy: Nerve Surgical Anatomy: Nerve SupplySupply• The adrenal cortex appears to have only vasomotor innervation.

• Most of the fibers, which reach the gland from the splanchnic nerves, lumbar sympathetic chain, celiac ganglion, and celiac plexus go to the medulla.

• These nerve fibers are preganglionic and end on the medullary chromaffin cells.

Summary of Surgical Summary of Surgical Indications for Indications for AdrenalectomyAdrenalectomy1. Primary hyperaldosteronism.

a. Unilateral cortical adenoma causing Conn's syndrome. b. Bilateral hyperplasia with unilateral dominance (established by adrenal vein sampling).

2. Hypercortisolism.a. Unilateral cortical adenoma.b. Refractory Cushing's syndrome (from Cushing's disease, primary adrenal hyperplasia, or

ectopic adrenocorticotropic hormone [ACTH] syndrome).

3. Pheochromocytoma.

4. Unilateral cortical adenoma causing virilization.

5. Myelolipoma (in selected situations).

6. Adrenal cyst (if refractory or symptomatic).

7. Adrenocortical carcinoma.

8. Incidentaloma with indeterminate or concerning imaging characteristics.

9. Adrenal metastases of other primary cancers (in selected situations).

Surgical Approaches for Surgical Approaches for AdrenalectomyAdrenalectomy

1.Open adrenalectomy:a. Transabdominal approach:

• Subcostal or Midline approach. • Thoracoabdominal approach.

b.Retroperitoneal approach.• Lumbodorsal posterior approach.• Flank approach.

2.Laparoscopic adrenalectomy:a. Transperitoneal Approach.b.Retroperitoneal Approach.c. Hand-assisted laparoscopic surgery.d.Robotic surgery.

Adrenalectomy: Choice of Adrenalectomy: Choice of ApproachApproach

• The decision to use one of these different operations to remove an adrenal mass depends on several different factors. Each of these factors is important and will be considered by the surgeon prior to beginning the operation. In fact, occasionally a surgeon will start the operation using a smaller or even laparoscopic approach, and decide half-way through the operation that to be safe and to assure the best chance of cure that the operation should be made larger.• Factors which determine which adrenal operation a surgeon will perform:


A. The type of the tumor: • All cancers require a larger more careful operation and

therefore must be removed through a larger operation. Cancers are not appropriately removed using minimal or laparoscopic operations.

B. The size of the tumor: • Since very large adrenal masses are more likely to be

cancer, they require a larger incision and a more careful dissection. Additionally, it is almost impossible to remove a large adrenal tumor laparoscopically because the surgeon cannot see around it with the camera.


C. History of previous abdominal operations: • If a patient has had previous abdominal operations then the

laparoscopic adrenalectomy can be more technically difficult. D. The surgeon's experience with different operations: • Surgeons tend to do what they do well. Laparoscopic

adrenalectomy was developed in the mid 1990's so it is NOT performed by all surgeons.

Open Open AdrenalectomyAdrenalectomy

Indications for Open Indications for Open SurgerySurgery

• The current indications for open adrenalectomy are few but important.

• First, adrenal cortical carcinoma with radiographic evidence of extra-adrenal tumor invasion of adjacent organs may benefit from maximal surgical exposure.

• Similarly, the extension of adrenal vein tumor thrombus into the inferior vena cava necessitates a more invasive approach.

• Finally, in developing countries, the resources for laparoscopic surgery may be lacking, and the open approach will be preferred out of necessity.

• The following table summarizes the best surgical approach for a given adrenal disease.

Indications for Open Indications for Open SurgerySurgery

Patient PreparationPatient Preparation

•General Preparation:

1. Nothing by mouth before surgery. 2. No preoperative antibiotics are necessary before surgery

except when the patient has other indications (eg, cardiac valvulopathy, orthopedic hardware).

3. Invasive blood pressure monitoring if required for pheochromocytoma or other medical condition.

4. Deep vein thrombosis (DVT) prophylaxis (for laparoscopic cases this should include sequential compression devices).

Patient PreparationPatient Preparation

• Disease-Specific Preparation:1. Preoperative control of hypertension for patients with

pheochromocytoma. 2. Stress-dose steroids administered to patients having

adrenalectomy for hypercortisolism (benign or malignant causes) due to suppression of hypothalamic-pituitary-adrenal axis involving the contralateral adrenal gland.

Open AdrenalectomyOpen Adrenalectomy• Open adrenalectomy can be performed through either a

transperitoneal or retroperitoneal approach. • The transperitoneal approaches include midline, subcostal, and

thoracoabdominal. The retroperitoneal approaches include flank and posterior lumbodorsal. • The advantages of the transperitoneal approaches are better

exposure for larger tumors and excellent access to the great vessels and retroperitoneum. The main disadvantages are prolonged ileus and difficult exposure in morbidly obese patients. • The retroperitoneal approach results in less ileus and may result in

shorter• hospital stays. There is a smaller operative field, and access to

larger tumors and surrounding involved organs may be difficult.

1- Subcostal Anterior 1- Subcostal Anterior ApproachApproach

• The anterior approach is useful for larger tumors and

can be extended to the contralateral side as a chevron

incision for treatment of bilateral lesions.

• This approach also affords excellent exposure of the

great vessels, in the event that lymph nodes or venous

tumor thrombus needs to be addressed.

1- Subcostal Anterior Approach: 1- Subcostal Anterior Approach: Left SideLeft Side

• The patient is placed supine on the surgical table. • A skin incision is made approximately two fingerbreadths below

the costal margin. This incision is extended medially to the midline or beyond, depending on the degree of exposure needed. • The external oblique, internal oblique, and transverse abdominal

muscles, and their corresponding fasciae, are divided laterally; the rectus muscle and the rectus sheath are divided medially. • The peritoneum is entered sharply, and the falciform ligament is

divided after it is clamped and ligated with a large-gauge vascular tie (No. 0 or 1 silk).

• The transperitoneal approach may be attempted through a midline incision or subcostal incision.

• The subcostal incision can be extended into a full chevron for bilateral adrenalectomy or if a large unilateral tumor is encountered.


• The peritoneum is entered sharply, and the falciform ligament is divided after it is clamped and ligated with a large-gauge vascular tie.

• Exposure of the left adrenal gland begins with an incision of the posterior parietal peritoneum lateral to the left colon (line of Toldt) is incised, and the left colon is mobilized medially.

• The splenic flexure is taken down by dividing the splenocolic ligament. Division of the lienorenal ligament will allow medial mobilization of the spleen.

• Care must be taken to prevent injury to the spleen or the splenic capsule, or to the splenic vessels and the tail of the pancreas. The latter are enveloped by the splenorenal ligament.

• Peritoneum lateral to left colon is incised at the line of Toldt and extended cephalad to the splenocolic ligament and inferiorly.

• Another approach to the left adrenal gland is by opening the lesser sac through the gastrocolic omentum, which may be incised longitudinally outside the gastroepiploic arcade. Care must be taken to prevent traction on the spleen or on the splenocolic ligament. The ligament may contain tortuous or aberrant inferior polar renal vessels or a right gastroepiploic artery.

• A third approach to the left adrenal gland, which may occasionally be useful when an adrenal lesion is anterior, is to gain exposure by an oblique incision of the left mesocolon. The arcuate vessels may be divided, but the major branches of the middle and the left colic arteries must be preserved. Taking care to avert excessive retraction will prevent injury to the wall of the left colon.


• Following any of the approaches to get an exposure posterior to the colon, the peritoneum under the lower border of the tail of the pancreas is incised medially about 10 cm.

• The pancreas can then be gently retracted upwards, preventing injury. This maneuver will expose the left adrenal gland on the superior pole of the left kidney, both of which are covered with the renal fascia (of Gerota).

• The gland will be lateral to the aorta, about 2 cm cranial to the left renal vein. Incision of the renal fascia completely exposes the adrenal gland and permits access to the adrenal vein.

• If the operation is to remove a pheochromocytoma, the adrenal vein should be ligated first to decrease the release of catecholamines into the circulation, during manipulation of the gland.

• After ligation and division of the left adrenal vein, medial attachments to the aorta can be taken with the harmonic scalpel or with careful dissection and ligation of small arterial vessels while gentle lateral traction is placed on the gland. The lateral and inferior attachments to the kidney can be taken by blunt and sharp dissection off of the renal capsule. Care must be taken to avoid hitting upper pole renal vascular attachments.


• After removal of the left adrenal gland, closure of the incision is performed with a running No. 1 polydioxanone suture in two layers. The deep layer consists of the transverse abdominal muscle, transverse fascia, internal oblique muscle and fascia, and posterior rectus sheath, and the superficial layer consists of the external oblique muscle and fascia, and the anterior rectus sheath.

1- Subcostal Anterior Approach: 1- Subcostal Anterior Approach: Right SideRight Side

• On the right, the anterior approach to the adrenal gland begins with the mobilization of the hepatic flexure of the colon. Sharp dissection is necessary to divide the posterior adhesions of the liver to the peritoneum. Remember that medial attachments may contain hepatic veins.

• Mobilization of the colon will expose the duodenum. The second portion of the duodenum is freed by incision of its lateral, avascular peritoneal reflection. It may now be separated from retroperitoneal structures and reflected forward and to the left (Kocher maneuver).

• Mobilization of the hepatic flexure of the colon and the Kocher maneuver on the duodenum will expose the vena cava, the right adrenal gland, and the upper pole of the right kidney. The surgeon must remember that the common bile duct and the gastroduodenal artery are also in this area.

• If the adrenal tumor is large or is obscured by the right lobe of the liver, additional exposure can be gained by reflecting the right lobe of the liver medially. The falciform and the triangular ligaments are incised anteriorly, laterally, and superiorly. Dissection of the bare area of the right lobe of the liver permits reflection of the right lobe medially.

1- Subcostal Anterior Approach: 1- Subcostal Anterior Approach: Right SideRight Side

• The inferior vena cava is exposed in its position directly posterior to the second portion of the duodenum and then cleared to show the right renal vein. The superior pole of the right kidney is located and exposed. • Usually, the principal adrenal vein is first identified and then

doubly ligated. The e surgeon then cautiously works about the medial and inferior edges of the gland and ligates the principal artery or accessory arteries in a similar manner. The many minor vessels encountered must also be either carefully ligated or secured with clips.• The operation is then continued in the same fashion as left side.

2- Thoracoabdominal Approach2- Thoracoabdominal Approach

• This approach is a maximally invasive way to ensure superb surgical exposure of the retroperitoneum, adrenal gland, and great vessels. •However, this exposure comes at a price: increased incisional pain, prolonged ileus, pulmonary morbidity, and a chest tube. The thoracoabdominal approach is reserved for large or invasive adrenal carcinomas.


• The patient is placed in an oblique position with the upper torso at a 45-degree angle to the table and the lower body flat on the table. A body roll is used to achieve the 45-degree position, and the right arm is placed in a sling with the arm bent at the elbow.• The incision extends from the angle of the eighth or ninth rib,

across the midline to the midpoint of the contralateral rectus muscle, just above the umbilicus.• The intercostal muscles and fasciae are divided. The costal

cartilage is divided with the surgical cautery. The incision is carried farther through the anterior and posterior rectus sheaths and the rectus abdominal muscle.


• The pleura is entered, and the lung is packed away with laparotomy sponges. The diaphragm is divided with the cautery. Do not cut directly to the center of the diaphragm because the phrenic nerve can be damaged.

• Once the diaphragm is divided, a self-retaining retractor is placed to expose the surgical area. The rest of the dissection is similar to that of the previously described techniques.

• Demonstration of the route of surgical dissection during thoracoabdominal incision.

• Incision at the eighth intercostal space. The costal margin, external intercostal muscle and fascia, and anterior rectus sheath are divided.

• The retractor is placed to expose the anatomy. The lung visible in this view is packed away with laparotomy sponges.

• Exposure of the adrenal.


• Closure of the incision requires closure of the diaphragm and reapproximation of the ribs.

• The diaphragm is closed with interrupted figure-of-eight stitches with nonabsorbable suture.

• A chest tube is placed before the anterior thorax is closed.

• The anterior thorax is closed with several interrupted No. 0 chromic sutures on blunt-tip liver needles around the superior border of the eighth rib and inferior border of the ninth rib. A No. 0 Prolene suture on a tapered needle is placed through the cut costal cartilage to bring the costal margin together. The chest tube is placed to a water seal and suction.

3- Flank Retroperitoneal 3- Flank Retroperitoneal ApproachApproach

• The retroperitoneal approach results in less ileus and may result in shorter hospital stays. • There is a smaller operative field, and access to larger tumors and surrounding involved organs may be difficult.

3- Flank Retroperitoneal Approach: 3- Flank Retroperitoneal Approach: Right SideRight Side

• The patient is positioned in the lateral decubitus position with the right side facing up. The bed is placed in maximal flexion, and the kidney rest is deployed to accentuate the space between the costal margin and iliac crest. Palpation is used to identify the course of the 11th rib.


• The skin and fat overlying the 11th rib are incised, and the fascia and muscle overlying the rib are divided.• Once the anterior surface of the rib is exposed, the anterior periosteum is

cauterized, and the periosteal elevator is used to scrape it off the anterior rib surface. The edges of the periosteum on the superior and inferior aspects of the rib should now be visible. The periosteal elevator is used to develop a plane between the posterior rib surface and the posterior leaf of the periosteum.• The periosteum is striped off the rib from the tip of the rib back toward

the paraspinal muscles. With the rib cutter, the 11th rib is excised. Next, the neurovascular bundle is identified and freed with sharp and blunt dissection to avoid injury during subsequent dissection and closure.


• The lumbodorsal fascia is entered sharply with Metzenbaum scissors, and blunt dissection is used to dissect the peritoneum off the transverse fascia anteriorly.

• The flank muscles and their accompanying fasciae are divided anteriorly—the external oblique, internal oblique, and transverse abdominal.

• Next, the posterior muscle diaphragmatic attachments are divided with cautery. The pleura is sharply and bluntly dissected off the superior edge of the 12th rib.

• The plane between the Gerota fascia and the peritoneum can be started with the cautery or sharp dissection. Once it is identified, this plane can be maximally developed with blunt dissection.

• The peritoneum needs to be freed from the superior aspect of the Gerota fascia as well. Once the peritoneum is mobilized, on the right side, the vena cava can be visualized, and with cephalad dissection, the adrenal gland and renal vein can be seen as well.


• Placement of a self-retaining retractor is essential for maximal exposure to be obtained.

• Dissection of the adrenal gland begins along the medial border of the gland with the vena cava. The overlying peritoneum is divided, and blunt dissection is used to expose the plane between the medial surface of the adrenal gland and the lateral surface of the vena cava.

• The adrenal vein is often difficult to identify until this plane is developed. The adrenal vein is dissected out with a right-angled instrument. Surgical ties or clips can be placed to ligate the adrenal vein. There are numerous arterial branches to the gland that can be ligated and divided individually.

• Once this is done, the psoas muscle is often visible posteriorly. Superior attachments are divided with the aid of surgical cautery. Downward traction on the kidney assists with this dissection. Inferomedial attachments to the kidney are taken with sharp or cautery hook dissection.


• Closure of the incision consists of a two-layer closure with a running No. 1 polydioxanone suture. • The deep layer consists of the transverse abdominal muscle,

internal oblique muscle, and fascia. • The outer layer consists of the external oblique muscle and

fascia. • Skin closure can be completed with surgical staples or

absorbable subcuticular suture.• Other authors have described supracostal technique with

intentional violation of the pleura. This approach may be helpful for larger tumors.

3- Flank Retroperitoneal Approach: 3- Flank Retroperitoneal Approach: Left SideLeft Side

• Dissection of the left adrenal gland is similar except that the aorta is visualized, and the adrenal vein originates from the renal vein.

4- Lumbodorsal Posterior 4- Lumbodorsal Posterior ApproachApproach

• The main advantage of this approach is the ability to easily access both adrenal glands for bilateral surgery. • The disadvantages include a limited operative field and

respiratory limitation. If bleeding is extensive, it can be difficult to control from this position.• The procedure has been extensively modified over time—with

or without rib resection, transthoracic through the diaphragm, or diaphragm sparing.• The posterior approach should not be used for large tumors or

adrenocortical carcinoma.

4- Lumbodorsal Posterior Approach: 4- Lumbodorsal Posterior Approach: Right SideRight Side

• The posterior approach requires prone positioning of the patient with arms extended cephalad. • An incision is made along the course of the right 11th rib. This

is taken down to the periosteum, and the rib resection is performed in a manner similar to that described for flank incision.

• Possible incisions for lumbodorsal approach.

4- Lumbodorsal Posterior Approach: 4- Lumbodorsal Posterior Approach: Right SideRight Side

• The diaphragm is dissected off the underlying peritoneum and liver. The peritoneum is then dissected off the Gerota fascia, which is retracted inferiorly.

• The right adrenal gland is approached by retracting the superior pole of the right kidney inferiorly. The posterior surface of the adrenal gland can then be dissected free from fatty tissue. The liver must be retracted upward as the apex of the gland is reached. The lateral borders are freed, leaving only the medial margins to remain attached.

• The right adrenal gland should be retracted laterally, and the arterial branches from the aorta and the right renal artery to the gland, should be ligated. The right adrenal vein should also be ligated. Its recommended to free up the vena cava far enough to ensure room for an angle clamp, should hemorrhage from the vena cava or adrenal vein require it.

4- Lumbodorsal Posterior Approach: 4- Lumbodorsal Posterior Approach: Left SideLeft Side

• Dissection of the left adrenal gland should begin on the medial aspect, with clips applied to the arteries as they are encountered. • Remember that the pancreas lies just beneath the gland and is

easily injured. • The last step in the posterior approach is to identify the left

adrenal vein, which usually emerges from the medial aspect of the gland and courses obliquely downward to enter the left renal vein. Undue traction on the gland can tear the renal vein.

• Bilateral posterior approach

Endoscopic Endoscopic AdrenalectomyAdrenalectomy

Endoscopic Endoscopic AdrenalectomyAdrenalectomy

• The technique of laparoscopic adrenalectomy was first introduced in 1992 and has rapidly gained popularity, largely because of the many advantages of minimally invasive surgery. Diminished pain, rapid rehabilitation and short hospitalization are all realized with laparoscopic adrenalectomy, making this the gold standard, of the present day, for removing most adrenal lesions.

• There are three vital considerations in selecting patients for laparoscopic adrenalectomy. First, malignant tumors or large pheochromocytomas are best treated by transabdominal or thoracoabdominal exposure. The potential reduction in operative trauma is insufficient justification for minimal access when radical resection is necessary.

• Second, the indications for surgery, perioperative biochemical testing, and pharmacologic coverage should be the same regardless of the method chosen for adrenal access.

• Third, only surgeons who have adequate experience in open adrenalectomy and have mastered the techniques of advanced laparoscopic surgery should perform the procedure.

• Although there are few absolute contraindications to laparoscopic adrenalectomy, tumors larger than 10 cm should not be approached laparoscopically, primarily because of the difficulty created by the tumors of this size in exposure and mobilization, rather than cancer risk. Tumors with evidence of invasion should also not be resected laparoscopically.

1- Laparosocpic Transperitoneal 1- Laparosocpic Transperitoneal ApproachApproach

• The transabdominal lateral laparoscopic adrenalectomy, provides the best overall access to the adrenal gland and the areas of adrenal exposure and dissection. • This approach enables gravity retraction of the surrounding organs

and simplifies exposure of the adrenal gland, and enables the surgeon to inspect the entire abdomen and use familiar anatomic landmarks.• Transperitoneal laparoscopic adrenalectomy can be performed

through either an anterior supine approach or a lateral approach (more common). In general, the anterior supine approach allows bilateral adrenalectomy without having to reposition the patient. The lateral position is advantageous because greater workspace is available secondary to gravity-assisted retraction of the bowel.

1- Laparosocpic Transperitoneal Approach: 1- Laparosocpic Transperitoneal Approach: Left SideLeft Side

• The patient is positioned in a modified flank position. The patient is angled back about 30 to 45 degrees.

• After insufflation of the abdomen, four trocars are placed along the left costal margin.

• The line of Toldt is incised and the left colon medially mobilized.

• The lienorenal and splenocolic ligaments are divided. The lateral and superior attachments of the spleen can be divided to facilitate medial mobilization of the spleen if necessary. In many cases, the spleen may fall away sufficiently by gravity without having to extend the dissection above the spleen.

• The renal vein and adrenal vein are dissected free. The left adrenal vein is dissected out, ligated, and divided. Surgical clips are used to control the adrenal vein.

• Adrenal arterial supply is divided as the adrenal is dissected free. The harmonic scalpel is effective for performing this dissection.

• The remaining attachments to the kidney are divided bluntly and with the hook cautery. The specimen is placed in an endoscopic bag and extracted.

• The operative field is examined, the trocar sites are closed with absorbable suture. A drain usually does not needed.

Patient position & port position

Incision of the line of Toldt and medial dissection of the left colon with cautery endoscopic scissors.

Exposure and dissection of the renal vein and left adrenal vein.

Ligation and division of left adrenal vein

Division of adrenal arterial supply and superomedial dissection with downward traction on the kidney

The adrenal gland is mobilized off the medial aspect of the kidney

Placement of specimen in endoscopic extraction bag

1- Laparosocpic Transperitoneal Approach: 1- Laparosocpic Transperitoneal Approach: Right SideRight Side

• On the right side, the approach is similar. • As on the left side, a four-trocar configuration is used. • The most medial trocar is used for liver retraction.• However, the duodenum must be dissected away by the Kocher

maneuver.

2- Retroperitoneal endoscopic 2- Retroperitoneal endoscopic ApproachApproach

• Although less popular, retroperitoneoscopic adrenalectomy may be ideal for nonobese patients who have had previous abdominal surgery and for patients undergoing bilateral adrenalectomy. • The potential advantage of this approach is the avoidance of the

peritoneal cavity, theoretically benefitting the incidence of postoperative ileus and intraabdominal adhesion formation. • This technique is less useful for lesions larger than 7–8 cm in

size due to limited working space.

2- Retroperitoneal Endoscopic Approach: 2- Retroperitoneal Endoscopic Approach: Left sideLeft side

• The patient is placed in lateral decubitus position with the left side up. The patient is placed in flexion, and the kidney rest is deployed to accentuate the left flank.

• A 12-mm incision is made near the tip of the 12th rib under the 11th rib. The underlying muscle and fasciae are divided with cautery until the lumbodorsal fascia is visible or palpable.

• The lumbodorsal fascia is divided with cautery or Metzenbaum scissors, and blunt finger dissection is used to develop a plane between the posterior Gerota fascia and the psoas fascia.

• With this plane developed, a retroperitoneal dissection balloon is placed and inflated. Typically, a laparoscope can be placed down the hollow shaft of the dissection balloon to visually confirm the accurate anatomic placement of the balloon between the kidney and psoas. A balloon-tip trocar is placed into the defect and secured in position. After insufflation of the retroperitoneum, a 5- or 10-mm trocar is placed at the angle of the paraspinal muscle and the origin of the 12th rib. A 5- or 10-mm trocar is placed about two fingerbreadths above the iliac crest near the anterior superior iliac spine.

2- Retroperitoneal Endoscopic 2- Retroperitoneal Endoscopic ApproachApproach

• The renal hilum is usually located fairly rapidly in the retroperitoneal approach by direct visualization of arterial pulsations. • The left adrenal vein can be isolated from its origin on the left renal vein.

The left adrenal vein is dissected out and ligated with surgical clips and divided. • The left adrenal gland is then dissected out as described previously;

small arterial branches can be clipped or divided hemostatically with a harmonic scalpel. • The specimen is placed in a specimen bag and extracted. • The trocar sites are closed with absorbable suture after hemostasis is

ensured. The right adrenalectomy is performed in similar fashion; anatomic relations of this approach are illustrated previously

Dissection of the left adrenal vein by the retroperitoneal approach

Ligation and division of left adrenal vein. The kidney is dissected away from the adrenal gland

Anatomic view of right adrenal gland from retroperitoneal approach

3- Robotic Surgery3- Robotic Surgery• There is growing interest in applying robotic technology to adrenal surgery.

Currently, the da Vinci Surgical Robotic System is the only commercially available product to perform these procedures.

• Desai and colleagues reported the first case of robotic adrenalectomy in 2002. Since the initial case report, there have been many larger experiences that show that robotic adrenalectomy is safe and effective.

• It remains to be seen if robotic adrenalectomy is superior to laparoscopy.

• The advantages of robotics should be the superior three-dimension visualization and hand-like dexterity of the robotic arms to perform the microdissection of the plane between the adrenal and the great vessels.

• However, these technical advantages do not appear to translate to any tangible benefit in operative outcomes despite the higher cost.

3- Robotic Adrenalectomy: 3- Robotic Adrenalectomy: TechniqueTechnique

• This transperitoneal technique is a variant on the laparoscopic approach. The patient is placed in flank position.

• After the patient is prepared and draped, pneumoperitoneum is established in the same manner as laparoscopic surgery.

• Based on the side treated, a total of 4 to 5 trocars are placed as outlined by diagrams.

• The remainder of the dissection and excision of the adrenal gland are similar to the laparoscopic surgery.

• To facilitate access to the upper areas of the retroperitoneum, the robot is docked at an angle at the head of the table as outlined in diagram.

• The third robotic arm or a locking forceps can be used to elevate and retract the liver during right adrenalectomy

4- Hand-Assisted Endoscopic 4- Hand-Assisted Endoscopic SurgerySurgery

• The advantage of hand assistance stems from the addition of tactile sensation. • This may result in faster dissection and added security in the

event of bleeding complications. • Also, the learning curve may be shorter with hand assistance.

Only case reports exist regarding hand-assisted laparoscopic adrenalectomy. • This may be especially advantageous for large adrenal tumors

that may require an incision for extraction. Bilateral tumors may also be treated in this fashion.

Complications of AdrenalectomyComplications of Adrenalectomy

• Operative Complications of Adrenal Surgery:

Complications of Complications of AdrenalectomyAdrenalectomy

• Postperative Complications of Adrenal Surgery:1. Hemorrhage.2. Pneumothorax.3. Pancreatitis.4. Pneumonia.5. Hiccups.

Alternatives for SurgeryAlternatives for Surgery•Radiofrequency Ablation.•Cryoablation.

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Surgical approaches to adrenalectomy

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Transcript of Surgical approaches to adrenalectomy