Minimally Invasive Adrenalectomy
Minimally Invasive Adrenalectomy
Minimally Invasive Adrenalectomy
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
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.
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
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
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.
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).
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.
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.
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
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.
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.
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
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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