Laparoscopic adrenalectomy is indicated for pheochromocytomas, and hormonally active adenomas that may secrete aldosterone, glucocorticoids, testosterone, or estrogen. Hormonally inactive lesions >3 cm that demonstrate growth over time on serial imaging studies or tumors >4 cm without evidence of growth are also an indication for laparoscopic adrenalectomy. Functional bilateral adrenal hyperplasia refractory to medical management, primary adrenocortical carcinoma, and solitary metastasis may be treated with laparoscopic adrenalectomy. However, great care should be taken when removing the adrenal metastases from the abdomen in cases of lung or renal cancer, as these are particularly prone to port-site metastasis.
For patients suffering from pheochromocytoma, an alpha blocking agent should be administered for at least 2 weeks prior to adrenalectomy with adequate control of blood pressure. Once adequate blood pressure control is achieved, a beta blocking agent may be added to facilitate heart rate control for pulse rates exceeding 100/min. For patients undergoing adrenalectomy for Cushing disease, a single stress dose of hydrocortisone should be administered intraoperatively, follow by a tapered dose regimen postoperatively.
General endotracheal anesthesia with complete neuromuscular blockade is required. An orogastric tube is placed after induction for decompression of the stomach, allowing better access to the operative site. Bilateral sequential compression devices are placed, as is a Foley catheter. Preoperative antibiotics are administered.
For the left adrenalectomy, the patient is placed on the operating room table in the right lateral decubitus position. This position is stabilized by a beanbag or large gel roll. The arms are supported by armboards in a neutral position. An axillary roll is placed to prevent nerve injury (Figure 1A). The bed is flexed to widen the angle between the anterior superior iliac spine and the costal margin (Figure 1B). A kidney rest can be employed to widen this angle if necessary. A pillow is placed between the knees. The patient is secured to the operating table with broad cloth tape, secured at the hips and across the chest. For the right adrenalectomy, this position is mirrored, with the right side of the patient elevated. The patient is shaved from the anterior midline to the posterior flank on the affected side between the xiphoid and the pubis, prepped in the same distribution, and draped in a sterile manner.
A thorough appreciation of the left upper quadrant regional anatomy is particularly important for the left adrenalectomy. Understanding the relationship of the tail of the pancreas, spleen, kidney, and adrenal gland is key to avoiding iatrogenic injury to any of these structures.
Initial port placement occurs with the patient in the ...