Minimally Invasive Adrenalectomy

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M inima lly I n vas i ve

A d ren a l e c t o m y
Azadeh A. Carr, MD, Tracy S. Wang, MD, MPH*

KEYWORDS
 Minimally invasive  Laparoscopic adrenalectomy  Adrenal incidentaloma
 Posterior retroperitoneoscopic adrenalectomy  Adrenal metastases

KEY POINTS
 Minimally invasive adrenalectomy is the preferred method for benign, accessible adrenal
masses.
 Adrenal imaging and biochemical evaluation are essential for characterization of adrenal
lesions.
 Patient selection for laparoscopic transabdominal and posterior retroperitoneoscopic
adrenalectomy (PRA) should be based on anthropometric parameters and characteriza-
tion of the adrenal mass.
 Minimally invasive adrenalectomy has been shown to be safe and efficacious for adrenal
metastases; however, open adrenalectomy is recommended in suspected or confirmed
primary adrenal malignancy for best oncologic outcome.

INTRODUCTION

With the increased use of abdominal imaging, adrenal neoplasms are being identified
more frequently.1,2 Autopsy studies have evaluated the frequency of incidental adrenal
masses and found that they are present in up to 6% of patients. There is an increasing
prevalence with age, as adrenal masses are present in less than 1% of patients
younger than 30 years and up to 7% of patients older than 70 years.3–8 Minimally inva-
sive adrenalectomy through a laparoscopic transabdominal approach was first intro-
duced in the early 1990s and has transformed the management of adrenal tumors.9
Since then, minimally invasive adrenalectomy has been shown to have less blood
loss, earlier patient mobility, decreased length of stay, and faster return to regular

The authors have nothing to disclose.


Section of Endocrine Surgery, Division of Surgical Oncology, Department of Surgery, Medical
College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
* Corresponding author.
E-mail address: [email protected]

Surg Oncol Clin N Am 25 (2016) 139–152


http://dx.doi.org/10.1016/j.soc.2015.08.007 surgonc.theclinics.com
1055-3207/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
140 Carr & Wang

activity.10–12 These advantages have led to increased frequency of surgery and evo-
lution of indications for adrenalectomy.13–15
Laparoscopic adrenalectomy has become the gold standard for removal of benign
adrenal masses. This article discusses the management of incidentally discovered
adrenal masses, indications for surgery, and surgical approaches, with a focus on
the transabdominal and retroperitoneal methods.

PATIENT EVALUATION AND INDICATIONS FOR ADRENALECTOMY

The initial presentation of an adrenal mass is frequently an adrenal incidentaloma,


defined as the identification of an unsuspected adrenal mass when imaging is per-
formed for other indications. Adrenal incidentalomas have been reported in up to
5% of patients undergoing abdominal computed tomographic (CT) scans for other in-
dications.16–18 Most adrenal masses are benign, although biochemical evaluation is
recommended in all patients with adrenal incidentalomas.2,19,20 Indications for adre-
nalectomy include a hormonally active adrenal tumor or a suspected or confirmed
malignancy.2,20,21 Adrenal malignancies may be either a primary adrenocortical carci-
noma (ACC) or metastases from another primary cancer.

Imaging of Adrenal Masses


The increased frequency and technological advances in abdominal imaging have led
to the increased identification of adrenal masses. Most often the imaging is obtained
for other indications and is not optimized for evaluating the adrenal glands.17 However,
some characteristics can be identified to broadly determine the nature of the lesion.
Common characteristics attributed to benign adrenal neoplasms are size less than
4 cm, smooth contours with planes between organs intact, and a homogenous den-
sity; in contrast, malignant neoplasms are frequently greater than 6 cm in size, have
irregular borders without clear planes, and are heterogeneous.1
Benign adrenal adenomas contain high amounts of intracytoplasmic fat; approxi-
mately 70% of adrenal adenomas are rich in lipids.22 This high lipid content allows
for the use of densitometry, measured as Hounsfield units (HU), to distinguish benign
and malignant lesions on unenhanced CT.1 Initial reports used an HU threshold of less
than 0 to indicate a benign lesion, with high specificity (100%) but poor sensitivity
(47%).23 A meta-analysis of 10 studies that evaluated 495 adrenal lesions (272 benign
and 223 malignant) by unenhanced CT found that an HU threshold of less than 10 had
a sensitivity of 71% and specificity of 98% for the diagnosis of an adrenal adenoma,
without further radiologic imaging.24 This method has become the standard for initial
evaluation of incidental adrenal lesions without intravenous contrast.1
Approximately 30% of adrenal masses may have an indeterminate HU (between 10
and 30), necessitating contrast-enhanced CT with delayed washouts.1 Because of
neovascularization, malignancies tend to have increased contrast accumulation; as
a result, intravenous contrast washes out from adenomas, both lipid rich and lipid
poor, more quickly than from adrenal malignancies and pheochromocytomas.25
Contrast washout can be calculated in 2 ways: absolute percentage washout (APW)
requires both noncontrast and contrast scans ([(enhanced HU delayed
HU)O(enhanced HU noncontrast HU)]  100), whereas relative percentage washout
(RPW) can be calculated based on an initial CT scan with contrast and delayed scans
only ([(enhanced HU delayed HU)Oenhanced HU]  100). In adrenal protocol CT
scans, initial noncontrast imaging is followed by contrast imaging; a 15-minute
delayed scan is then performed. Adrenal masses with initial noncontrast HU less
than 10 do not warrant contrast imaging.2,26 A 2002 prospective study of 166 adrenal
Minimally Invasive Adrenalectomy 141

masses imaged using this protocol found that an APW threshold of greater than 60%
had a sensitivity of 86% and specificity of 92% for distinguishing lipid-poor adenomas
from nonadenomas and an RPW threshold of 40% had a sensitivity of 82% and spec-
ificity of 92%.26,27 Other studies have confirmed these thresholds using 15-minute
delayed imaging.22,25,27–29
MRI may also be used for the characterization of adrenal lesions. Malignant adrenal
lesions tend to contain more water and less fat than benign lesions and therefore have
higher signal on T2 images, although pheochromocytomas may also have a similar
appearance.1,20 When gadolinium contrast is used, adenomas appear more homog-
enous, whereas malignancies are heterogeneous. However, there is significant over-
lap in the characteristics of benign and malignant lesions; therefore, MRI may not
definitively distinguish adenomas from malignant masses.30
Adrenal lesions not well characterized by CT or MRI may benefit from radionuclide
adrenal imaging with specific radiolabeled compounds that target elements of adrenal
function and help characterize lesions.31,32 These radiotracers may include meta-
iodobenzylguanidine (MIBG) for medullary tissue lesions and fludeoxyglucose F 18
(18F FDG) for malignant tumors.33 MIBG imaging may identify both nonhypersecreting
and hypersecreting adrenal medulla lesions with a positive predictive value of 83%.32
18
F FDG-PET/CT has a sensitivity 99% to 100% and specificity of 94% to 100% for
identifying malignant lesions.32,34,35

Biochemical Evaluation of Adrenal Tumors


Initial evaluation of an adrenal mass should be to determine functional status.5,36 A
thorough history and physical examination should be obtained, with specific questions
related to eliciting symptoms of excess production of aldosterone, cortisol, or cate-
cholamines (Table 1).2,5 Evaluation should include assessment of other constitutional
symptoms, including weight loss, history of cancer, and smoking history, as a primary
ACC or adrenal metastases must also be considered in the differential diagnosis.

METASTASES TO THE ADRENAL GLAND

Isolated adrenal metastases are most commonly from a primary lung cancer, but other
sites of primary malignancy include breast, melanoma, kidney, colon, stomach, and
lymphoma.37–39 The benefits of surgery for metastatic disease are controversial, but
studies have demonstrated improved survival in properly selected patients. Adrenal
metastases should be suspected in patients with known history of cancer who are
found to have an adrenal mass on initial workup or routine surveillance of the primary
malignancy. Evaluation should include comparison to prior imaging and biochemical
evaluation for a functional adrenal tumor.2,40
According to the American Association of Clinical Endocrinologists (AACE) and
American Association of Endocrine Surgeons (AAES) guidelines on the management
of adrenal incidentaloma, a thorough evaluation for locoregional recurrence and other
metastatic sites is required if an adrenal metastasis is suspected.2 Adrenalectomy can
be considered to improve disease-free survival in appropriately selected patients
without significant other sites of disease and good performance status. Given the
safety of minimally invasive surgery, it should be considered as a first-line approach
for isolated adrenal metastases.
Several studies have examined the outcomes of patients undergoing adrenalec-
tomy for adrenal metastases. A retrospective review from the Mayo clinic matched
166 patients who underwent adrenalectomy for adrenal metastases to Surveillance,
Epidemiology, and End Results (SEER) data of similar patients who did not undergo
142 Carr & Wang

Table 1
Evaluating for hormonal excess in adrenal tumors

Signs/Symptoms Biochemical Evaluation


Cushing’s syndrome  Weight gain  Overnight 1 mg dexamethasone
 Easy bruising suppression test
 Acne  24-h urine free cortisol
 Proximal muscle  Late-night salivary cortisol (at least
weakness 2 tests)
 Striae
 Fatigue
 Neuropyschological
disturbances
 Hypertension
 Glucose intolerance
 Hyperlipidemia
 Menstrual abnormalities
Pheochromocytoma  Severe headache  Plasma free metanephrines
 Weight loss  24-h urine fractionated metanephrines
 Anxiety and catecholamines
 Sweating
 Cardiac arrhythmia
 Palpitations
 Syncope
Primary aldosteronism  Hypertension (often Plasma aldosterone/renin ratio
refractory)
 Fluid retention
 Hypokalemia
 Muscle cramps
 Polyuria
 Palpitations

Data from Young WF Jr. Clinical practice. The incidentally discovered adrenal mass. N Engl J Med
2007;356(6):601–10; and Zeiger MA, Siegelman SS, Hamrahian AH. Medical and surgical evaluation
and treatment of adrenal incidentalomas. J Clin Endocrinol Metab 2011;96(7):2004–15.

adrenalectomy.41 Patients with primary soft-tissue, kidney, lung, and pancreatic tu-
mors were found to have better overall survival at 3 years: sarcoma (86% vs 30%), kid-
ney (72% vs 27%), lung (52% vs 25%), and pancreas (45% vs 12%). In this study, risk
factors for death included shorter interval from primary diagnosis to adrenalectomy,
other distant sites of disease, surgery for palliation, and persistent disease. A retro-
spective European multicenter review identified 317 patients who underwent adrenal-
ectomy for adrenal metastases; the most common primary tumor was non–small cell
lung cancer (47%), followed by colorectal (14%) and renal (12%) cancers.39 Laparo-
scopic adrenalectomy was performed in 146 (46%) patients. Median overall survival
was 29 months, with 3- and 5-year survival of 42% and 35%, respectively. Patients
who underwent laparoscopic adrenalectomy had improved survival (hazard ratio,
0.65; 95% confidence interval, 0.47–0.90).
Laparoscopic adrenalectomy has been shown to be safe and oncologically appro-
priate for adrenal metastases. A retrospective review of 92 patients undergoing adre-
nalectomy (94 adrenalectomies: 63 open and 31 laparoscopic) for isolated adrenal
metastases found a median overall survival of 30 months and 5-year estimated survival
of 31%.42 In comparing laparoscopic with open surgery, there was no difference in
local recurrence, margin status, disease-free interval, or overall survival. Laparoscopic
adrenalectomy was associated with decreased blood loss (106 vs 749 mL; P<.0001),
Minimally Invasive Adrenalectomy 143

operative time (175 vs 208 minutes; P 5 .04), length of stay (2.8 vs 8.0 days; P<.0001),
and complication rates (4% vs 34%; P<.0001). A more recent study of 90 patients who
underwent adrenalectomy for adrenal metastases found that laparoscopic adrenalec-
tomy, performed in 55 (61%) patients, was associated with smaller tumor size and
reduced blood loss, operative time, and length of stay.38 Median overall survival was
2.46 years (range, <1 month to 15 years) and 5-year survival was 38%, with no differ-
ence in overall survival between laparoscopic and open adrenalectomy.

PREOPERATIVE PREPARATION

Preoperative preparation depends on the functional status of the mass. For patients
with a pheochromocytoma, preoperative a-adrenergic blockade is necessary to
decrease risk of perioperative cardiovascular complications.43 Medication should
be started 7 to 14 days before planned surgery for adequate time to correct blood
pressure and heart rate. b-Adrenergic blockade should be initiated for reflexive tachy-
cardia only after appropriate a-blockade. Patients should also be encouraged to in-
crease sodium and fluid intake to counteract the catecholamine-induced volume
contraction. It is important that preoperative consultation and discussion is arranged
with the anesthesia team so they are prepared to manage hemodynamic changes dur-
ing the procedure. For patients with cortisol production, patients may require periop-
erative steroids with outpatient follow-up for monitoring and tapering of steroids.

APPROACHES TO SURGERY: LAPAROSCOPIC TRANSABDOMINAL VERSUS POSTERIOR


RETROPERITONEOSCOPIC ADRENALECTOMY

The laparoscopic transabdominal and posterior retroperitoneoscopic approaches to


adrenalectomy both afford specific advantages and disadvantages (Table 2).44

Table 2
Advantages and disadvantages of laparoscopic transabdominal and posterior
retroperitoneoscopic adrenalectomy

Advantages Disadvantages/Contraindications
Retroperitoneoscopic  Do not have to mobilize other  Not suitable for obese patients
organs  Short distance between 12th rib
 Not affected by prior abdominal and iliac crest (<4 cm)
surgery  Not suitable for known or highly
 No intraperitoneal insufflation suspected malignant tumor
(for patients with potential (ACC or pheochromocytoma);
cardiovascular or respiratory evidence of invasion into adja-
compromise) cent structures
 Same position for bilateral
adrenalectomy
Laparoscopic  Can be combined with other  Need to change position for
transabdominal transabdominal procedure bilateral adrenalectomy
 Easier access for conversion to  Need to mobilize abdominal
open procedure structures
 More suitable in obese patients  Not suitable for known or highly
suspected malignant tumor
(ACC or pheochromocytoma);
evidence of invasion into adja-
cent structures

Data from Callender GG, Kennamer DL, Grubbs EG, et al. Posterior retroperitoneoscopic adrenal-
ectomy. Adv Surg 2009;43:147–57.
144 Carr & Wang

Proper patient selection is essential, with minimally invasive adrenalectomy not rec-
ommended for suspected or known ACC.45 The transabdominal approach was initially
widely adopted as the view is more familiar to most surgeons and allows for combina-
tion with other abdominal procedures.20 This approach requires mobilization of the co-
lon, spleen, and pancreas (left) and liver (right), and intra-abdominal adhesions from
prior surgical procedures may be present. Retrospective review of laparoscopic trans-
abdominal adrenalectomy in patients with prior abdominal surgery has shown it to be
safe, without significantly increasing operative time, complication rates, conversion to
open surgery, or length of stay.46,47
PRA provides direct access to the adrenal gland without requiring mobilization and
retraction of other organs.48 A retrospective review suggested a selection algorithm
for the 2 procedures by comparing anthropometric parameters between 52 patients
who underwent laparoscopic transabdominal adrenalectomy and 30 patients who
underwent PRA.49 They recommended selection for PRA if distance from Gerota’s
fascia to the skin was less than 5 cm and the 12th rib was at or rostral to the level
of the renal hilum. The transabdominal approach was recommended in obese patients
with thick perinephric fat, a long distance from Gerota’s fascia to skin, and tumors
greater than 6 cm, as the limited space in PRA makes this dissection especially chal-
lenging. In a retrospective review of 118 PRAs comparing the authors’ initial experi-
ence with PRA to their more recent experience, the authors noted a decrease in
rates of complications (15.9% vs 7.7%, P 5 .29) and conversion to an open procedure
(9.5% vs 1.9%, P 5 .19), although neither reached statistical significance.50 However,
the authors did gain increasing comfort with patients with higher body mass index
(BMI), successfully performing PRA on 55 patients with BMI 30 or more and 17 pa-
tients with BMI 35 or more, despite longer operative times than in patients with BMI
less than 30 (106 vs 125 minutes, P 5 .01).

SURGICAL TECHNIQUE: LAPAROSCOPIC TRANSABDOMINAL ADRENALECTOMY


Patient Positioning
Patients should be placed in a supine position on the operating table; a bean bag
should be placed below the patient. After the induction of general anesthesia, an oro-
gastric tube and Foley catheter are usually placed, both of which may be removed at
the end of the procedure. The patient is turned to a lateral decubitus position with the
affected side up. An axillary roll is placed, and the elevated arm is secured on an
elevated arm board. Pillows are placed between the legs, with the lower leg flexed
and the upper leg straight. The superior iliac spine should be positioned at the break
point in the operating table and the bed is flexed to increase working space.
The patient should be prepared and draped down to the midline of the abdomen
(Fig. 1). Landmarks that should be noted, the costal margin and the midline, are
marked. The Veress needle or Hasson technique may be used for access into the
abdomen. The initial entry is made at the anterior axillary line, 2 cm below the costal
margin. The authors prefer to use the Hasson technique with a balloon-tip adjustable
10- to 12-mm trocar and a 10-mm 30 laparoscope. The abdominal space should be
insufflated to 15 mm Hg, and after inspection for intra-abdominal adhesions, additional
5-mm ports are placed medial and lateral to the initial port, making sure that port sites
are greater than 5 cm apart to allow for mobility of the laparoscopic instruments.

Right Laparoscopic Transabdominal Adrenalectomy


For a right adrenalectomy, the patient is positioned with the right side up, and after
placement of the ports, dissection is begun by incising the right triangular ligament.
Minimally Invasive Adrenalectomy 145

Fig. 1. Positioning for left laparoscopic transabdominal adrenalectomy. Solid line marks the
costal margin and dotted line marks the anterior midaxillary line.

Most of the dissection should be performed with an ultrasonic or bipolar device. This
incision should be carried up to the level of the diaphragm. A fourth port is often used
(placed through the falciform ligament, in the midline of the abdomen), to allow use of a
gentle liver retractor. Once the liver is completely mobilized, it should be retracted
medially, allowing for visualization of the adrenal gland and the inferior vena cava
(IVC). The right adrenal vein empties directly into the IVC and is identified by gentle
dissection of the gland on its medial border. The plane between the adrenal gland
and IVC should be gently created, using blunt dissection and electrocautery. The ad-
renal vein should be carefully delineated and be doubly ligated with clips. If the adrenal
vein cannot be safely ligated with clips alone, a vascular stapler may be used. After the
vein has been secured, the rest of the medial and inferomedial attachments are
divided. The gland is then elevated, and the remainder of the avascular posterior
and lateral attachments are ligated. The gland is placed in a retrieval bag and removed
from the 12-mm port site, which may need to be increased in size to allow for safe
removal of larger adrenal glands. The fascia for the 12-mm trocar site should be closed
at the end of the procedure.
Throughout the procedure and dissection, it is important to avoid undue pressure,
retraction, or grasping of the adrenal gland, as this may cause fracture or tearing of the
gland. If surgery is being performed for a pheochromocytoma, constant communica-
tion with the anesthesia team is essential, including notifying the team when the adre-
nal vein is being ligated. The anesthesia and surgical teams must be ready for
significant alterations in blood pressure and may need to pause dissection for
addressing these needs.

Left Laparoscopic Transabdominal Adrenalectomy


Left adrenalectomy may be performed with 3 ports, although an additional medial port
may be used to aid in retraction (Fig. 2). The first step is mobilization of the splenic
flexure of the colon. This step may need to be performed before the most lateral
port can be placed. The splenorenal ligaments are then divided up to the diaphragm
to allow the spleen to be retracted medially. Caution must be taken at this point to
create a proper plane between the pancreas and the left kidney; Gerota’s fascia
should not be accessed. With the spleen and tail of the pancreas mobilized medially,
an additional medial port may be placed to aid in retraction. The adrenal gland should
now be seen adjacent to the superior pole of the kidney. The medial border of the ad-
renal gland should be dissected free with a combination of blunt dissection and elec-
trocautery, again using the ultrasonic device. On the left, the adrenal vein drains into
the renal vein and may be seen inferomedial to the adrenal gland (Fig. 3). Once it is
146 Carr & Wang

Fig. 2. Port placement for left laparoscopic transabdominal adrenalectomy.

properly dissected free, it should be ligated with a clip applier. The inferior phrenic vein
may also enter into the adrenal vein and may require ligation. After the adrenal vein is
ligated, the remaining attachments of the gland can be divided. The inferior portion of
the gland is elevated to aid in division of the posterior attachments and small arterial
branches. Once the gland is completely free, it may be placed into a retrieval bag for
removal.

SURGICAL TECHNIQUE: POSTERIOR RETROPERITONEOSCOPIC ADRENALECTOMY

The technique for PRA has been extensively described by Walz and colleagues51 and
is summarized here.52,53 Patients are intubated in the supine position after placement
of sequential compression devices and a Foley catheter. The patient is then turned to
the prone, jackknife position on a Cloward table (Surgical Equipment International,
Honolulu, HI), which has an open space for the abdomen between the hip support
to allow contents to fall forward, being careful to place appropriate padding for the pa-
tient’s face (Fig. 4A). The arms are positioned on arm boards, with elbows bent at 90
angle. The hips and knees are also bent at a 90 angle, ensuring that the knee rest is
low enough to limit pressure on knees and prevent the hips from being elevated, which
can narrow working space.
The landmarks that should be noted in this position are the 12th rib and iliac crest.
The initial incision is made just below the tip of the 12th rib. Using sharp dissection with
Metzenbaum scissors, the underlying soft tissue is incised and the retroperitoneum is
accessed. The index finger is used to create space, and under direct palpation, a
5-mm port is placed medially, just lateral to the paraspinous musculature. The lateral

Fig. 3. Left adrenal vein (no fill arrow) entering into left renal vein (solid arrow).
Minimally Invasive Adrenalectomy 147

Fig. 4. Right posterior retroperitoneoscopic adrenalectomy. Patient positioning on Cloward


table (A). After working space is created in the retroperitoneum, dissection begins by sepa-
rating the lower aspect of the adrenal gland from the superior pole of the kidney (B). (From
Dickson PV, Jimenez C, Chisholm GB, et al. Posterior retroperitoneoscopic adrenalectomy: a
contemporary American experience. J Am Coll Surg 2011;212(4):660; [discussion: 665–7];
with permission.)

5-mm port is also placed under direct palpation, 5 cm lateral to the initial incision. A
blunt 12-mm trocar with inflatable balloon and adjustable sleeve is then placed
through the initial (middle) incision. The retroperitoneal space is then insufflated with
high flow to a pressure of 20 to 24 mm Hg. This high insufflation pressure allows the
retroperitoneal space to be adequately opened and helps prevent bleeding from
smaller veins to aid in dissection. A 10-mm 30 laparoscope is placed in the middle
trocar, with the surgeon working through the medial and lateral trocars to ligate the
tissues of the retroperitoneum. Once the retroperitoneal space has been developed,
a 5-mm 30 laparoscope is used, via the most medial port, and the lateral 2 ports
are used by the operating surgeon.
The first landmark to be identified with careful blunt dissection is the superior pole of
the kidney. During a right adrenalectomy, the IVC is seen medially, although it may be
significantly decompressed because of the high insufflation pressure (see Fig. 4B).
Mobilization of the adrenal gland should always begin inferiorly; this is done by gently
pushing down on the kidney with a laparoscopic peanut and lifting the adrenal supe-
riorly. The tissue along the superior border of the kidney is gently divided using an ul-
trasonic coagulator or bipolar device. This plane should be created first, as it is easier
to accomplish with the other attachments in place with minimal manipulation of the ad-
renal gland. The adrenal vein should then be identified, medial to the adrenal gland.
After it has been carefully dissected free, the vein is grasped on its distal side (closest
to the adrenal) with a grasper, clips are doubly placed on the proximal side, and the
vein is divided using electrocautery. The rest of the adrenal attachments are then
148 Carr & Wang

ligated. A retrieval bag is then inserted through the middle port, and the gland is
removed. The trocar is then replaced, and the retroperitoneal space is inspected for
hemostasis. To visualize any venous bleeding that may have been masked by the
high insufflation pressure, the pressure is lowered to 8 to 12 mm Hg. Once hemostasis
has been confirmed, the ports are removed, the larger port is closed in layers, and the
skin is closed at all sites with absorbable suture. Occasionally, a tear may occur in the
peritoneum, which may result in pneumoperitoneum as well. These tears do not have
to be closed and usually do not interfere with the procedure.

OTHER APPROACHES TO ADRENALECTOMY

With the continued advances in minimally invasive procedures, there is the drive to
identify ways to expand current methods. The first robotic adrenalectomy was re-
ported in 2001.54 Since then, the robotic approach has been used for both transabdo-
minal adrenalectomy and PRA. Multiple studies have shown no significant difference
in rates of conversion to open adrenalectomy, complications, or blood loss between
robotic and laparoscopic adrenalectomy, and although operative times may be initially
longer, this seems to improve with increasing experience.55–58 However, use of the
robot requires availability of the instrument, specific training, and a learning curve
separate from laparoscopy alone. The advantages of robotic adrenalectomy may
include improved ability to perform cortical sparing adrenalectomy in patients with fa-
milial syndromes who may require bilateral adrenalectomy to avoid steroid depen-
dence and for the posterior approach it may be useful in patients with glands
located superior to the 12th rib.59
Another area of interest has been single-incision minimally invasive surgery. It has
been used for both PRA and for the transabdominal approach. Reported studies
have shown overall no significant difference in operative time and complications; how-
ever, significant benefits have also not been demonstrated.60,61 Although this method
has been shown to be feasible, further studies are needed to determine risks and
benefits.

INDICATIONS FOR OPEN SURGERY

Since the introduction of minimally invasive adrenalectomy, its use for cases of sus-
pected adrenocortical malignancy has been controversial. ACC is a rare malignancy,
with an incidence of 1 to 2 per million per year with a high rate of recurrence and poor
long-term survival.62 Proponents of open surgery contend that ACC tends to invade
through the tumor capsule with microscopic disease present at the gland surface,
which laparoscopy can disrupt and spread.21 The AACE/AAES recommends that
open adrenalectomy be performed for suspected ACC with lymphadenectomy, with
a goal to leave the capsule intact to reduce risk of local recurrence.2,62 However,
the European Society of Endocrine Surgeons position statement on malignant adrenal
tumors states that laparoscopic resection may be performed for ACC or potentially
malignant tumors with preoperative and intraoperative stage I–II ACC and diameter
less than 10 cm.63
There are inconsistent data on the safety and efficacy of minimally invasive surgery
for suspected ACC, which is hindered by the rarity of the disease. Studies have
demonstrated increased recurrence rates and decreased disease-free and overall
survival in patients undergoing laparoscopic adrenalectomy for ACC.64–67 Other Euro-
pean studies have found that laparoscopic adrenalectomy may have an outcome
similar to open adrenalectomy for ACC, with no significant difference in both local
and distant recurrence rates and disease-free or overall survival.68,69 The differing
Minimally Invasive Adrenalectomy 149

data and recommendations demonstrate the continued controversy and regional


differences.

SUMMARY

Minimally invasive adrenalectomy has become the standard operative approach for
adrenal resection in the appropriate clinical setting. Both the laparoscopic transabdo-
minal and posterior retroperitoneoscopic approaches have been shown to be safe and
effective for most adrenal pathologies. PRA may be preferred in patients with prior
abdominal surgeries or bilateral adrenal disease, whereas laparoscopic transabdomi-
nal adrenalectomy is recommended in the obese and morbidly obese. The authors
continue to recommend that open adrenalectomy be performed for all patients with
known or suspected ACC.

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