Laparoscopic Adrenalectomy

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Michel Gagner
Laparoscopic Adrenalectomy
Wahjoe Djatisoesanto
The incisions used during laparoscopic procedures do not tell the entire story.
The cuts are small on the outside, a great amount of work is done on the inside.
Introduction
• Laparoscopic adrenalectomy was described in 1992 by
Gagner et al.
• Laparoscopic adrenalectomy has become the gold
standard for the surgical treatment of most adrenal
problem.
• The benefits: decreased hospital stay, shorter recovery
time and improved patient satisfaction (decreased post-op
pain and better cosmetic).
Indications
• The most common indication is a unilateral benign adrenal lesion:
– Incidentalomas
– Pheochromocytomas
– Aldosteronomas
– Cushing’s syndrome
• Less common
– Adrenal cysts
– Myelolipomas
– Androgen-secreting tumors
– Ganglioneuromas
– Adrenal hemorrhage
Contraindications
• Tumors larger than 12 cm likely containing
malignancy and local invasion.
• Metastatic adrenal disease and adrenocortical
carcinoma (still debate)
• Obesity, significant cardiopulmonary disease,
coagulopathy (relative contraindications).
Operative technique
• The laparoscopic approach to the adrenals
– Transperitoneal adrenalectomy anterior (ATA)
– Lateral transperitoneal adrenalectomy (LTA)
– Retroperitoneal adrenalectomy (REA)
• No evidence indicating that one approach is superior
to the other.
• Which approach to use depends on personal
preferences
Transperitoneal Laparoscopic
Adrenalectomy
Laparoscopic right adrenalectomy
The right adrenal gland
• Larger than the left one
• An endocrine organ with a variable
shape
• Located at the medial aspect of the
upper pole of the right kidney
• Retroperitoneal position and not
attached to the kidney
Operating room set-up
• General anesthesia
• Full left lateral decubitus position
• Both legs slighly flexed to avoid
crural neuropathy
• Cushion placed under left flank
• Table flexed to widen the space
between the anterior iliac spine
and inferior costal margin
Position
• 1. The Surgeon stands on the abdominal side of the patient.
• 2 and 3. Two assistants stand on the other side of the patient.
• Two video monitors are used.
Team
1. Operating table
2. Anesthetic equipment
3. Laparoscopic units
4. Monitor
5. Electrocautery
6. Instrument table
Equipment
Pneumoperitoneum
• A pneumoperitoneum at 12-15 mmHg is established in a
standard fashion according to the operating surgeon’s
preference.
• Only 4 trocars (10mm) are necessary to perform a
laparoscopic right adrenalectomy transperitoneal
approach.
• The position of the trocars may vary with the patient’s
body habitus.
• The first 10 mm optical trocar is
inserted in the anterior axillary line,
under the costal margin.
• The 0° laparoscope is introduced
through this trocar.
• It is preferable to introduce this first
trocar under direct vision using the
open technique.
A second 10 mm trocar is introduced 5 cm from the optical trocar,
2 cm anterior to the anterior axillary line.
• Two other 10 mm trocars are introduced
under direct vision.
• Both are placed under the costal margin, 7
cm on either side of the optical trocar.
• Initially, a grasper is introduced through
each trocar and used to expose the
operating field to be dessected.
• The liver retractor will be introduced
through the trocar on the left.
A 0° laparoscope is commonly used.
A 30° laparoscope may be necessary, especially:
• In obese patients
• In case of large tumors
Operating devices
Other devices
Mayor principle
• Based on complete dissection of the right
adrenal gland without specifically identifying the
gland itself.
• The vena cava constitutes the main anatomical
landmark in this strategy.
• It is dissected first because it is easily identified
and leads directly to the right adrenal gland.
• The adrenal gland is located along the upper
pole of the internal aspect of the kidney and
sometimes covering it.
• The gland is surrounded by fatty tissue.
• It is firm yet extremely friable and therefore
particularly difficult to manipulate during
surgical procedures.
• The procedure begins with the incision of the subhepatic peritoneum
using either a coagulating hook or scissors.
• Frees the triangular ligament from the liver, resulting in the complete
mobilization of the liver
• The gallbladder, which is situated outside of the operating field, is left
untouched.
Dissection
1.
Mobilization of the liver allows identification of the vena cava.
2.
Exposing the renal vein: the vena cava is dissected caudally and
then cephalad.
3.
The main adrenal vein
1.
The main adrenal vein
2.
The accessory adrenal vein
• The main adrenal vein therefore easily dissected for 1 cm and
clipped under optimal safety conditions with 2 clips.
• The vein is then divided and the gland retracted caudally.
Captions
• The middle adrenal artery, which originates from the aorta, is
located either posterior or inferior to the main adrenal vein.
• It’s identified and dissected from the aorta in the fatty tissue,
and then clipped and divided.
• The superior adrenal artery, which originates from an inferior
phrenic artery, is identified at the upper pole of the gland
below the liver.
• It is dissected, clipped, and divided.
• The inferior adrenal artery, which usually originates from the
renal artery, is located on the postero-inferior aspect of the
gland.
• Clipping and division of the inferior adrenal artery.
• The inferior pole and internal aspect of the gland are then
completely freed from both the vena cava and the renal
vessels.
Captions
End of the dissection
• The vascular network of the gland is almost completely
divided.
• The goal is to free the gland completely and proceed to its
extraction.
• The few attachments are carefully dissected using either a
monopolar coagulating hook or a bipolar grasper.
Conclusion
• Laparoscopic adrenalectomy is the gold standard for removal of
adrenal tumor.
• There are three kind approach: Anterior transperitoneal, Lateral
transperitoneal and Retroperitoneal adrenalectomy.
• Malignancy is no longer considered an absolute contraindication to
the laparoscopic approach, unless invasion of the nearby organs or
the vasculature has occurred.
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