Plate 148

The presence of cortical or medullary tumors of a benign nature is a well-established indication for unilateral laparoscopic adrenalectomy. These tumors may be functional and produce cortisol, aldosterone, catecholamines, and rarely testosterone and other sex hormones. In many cases the tumors are nonfunctional and are removed because of the concern for cancer. In these situations the adrenal mass is frequently found during abdominal imaging done for unrelated indications. These so-named adrenal “incidentalomas” should be removed if they have a cross-sectional diameter 4 cm or greater or if they are proven to be functional. Patients with nonfunctional adrenal masses less than 4 cm should be followed with periodic imaging to monitor changes in the size of the mass. A benign adenoma on CT is typically a homogeneous mass with a low attenuation value (less than 10 HU). It is recommended that patients with an incidentaloma should have a 1-mg dexamethasone suppression test and a measurement of plasma-free metanephrines. In addition, patients with hypertension should have determinations of serum potassium and plasma aldosterone concentrations to plasma renin for an activity ratio. Surgery is considered in all patients with functional adrenal cortical tumors. All patients with biochemical evidence of pheochromocytoma should undergo surgery except in rare instances. Although size is not an absolute contraindication to laparoscopic adrenalectomy, the procedure may be difficult on lesions greater than 10 cm. Open adrenalectomy with en bloc excision is the mainstay for primary and recurrent adrenocortical carcinoma due to the lack of effective adjuvant therapy and the difficulty of maintaining oncologic principles with laparoscopy.

The most important preoperative procedure is to establish a firm diagnosis. Accordingly, the reader should refer to current texts on diagnostic endocrinology for the required procedures. When adrenalectomy is decided upon, the surgeon should investigate and, if possible, correct many of the secondary systemic and metabolic effects that are the direct result of the altered functional activity of the adrenal. The management of the hypertension and its cardiovascular sequelae is the major problem with pheochromocytomas. Preoperative treatment with an alpha-receptor antagonist such as phenoxybenzamine hydrochloride and volume expansion is necessary in patients with pheochromocytoma in order to control the associated hypertension. This may take two weeks or more. Beta-blockers are reserved for patients with tachycardia or cardiac arrhythmias. Problems associated with hypercortisolism have been reviewed in the section on bilateral adrenalectomy.

Preoperative consultation and communication among endocrinologist, surgeon, and anesthesiologist are necessary. A type and screen is acceptable for small tumors. Autologous donation or type and cross to ensure the availability of blood products is recommended for tumors greater than 6 cm. General anesthesia with endotracheal intubation is preferred in all cases. A catheter should be placed in the urinary bladder for monitoring urine output. The stomach should be decompressed with an orogastric or nasogastric tube. For patients with nonfunctional tumors, there are no special considerations for anesthesia. Patients with hyperaldosteronism should have the blood pressure controlled preoperatively, but rarely have life-threatening intraoperative hypertension. Patients with hypercortisolism should have correction of the metabolic abnormalities and be given a stress dose of steroids.

Patients with pheochromocytoma should have an arterial line and central line placed. In some patients with associated hypertensive cardiomyopathy, a pulmonary artery catheter may be helpful. During the procedure the anesthesiologist should be prepared to control hypertension with an intravenous infusion of sodium nitroprusside (Nipride). After the pheochromocytoma is removed and ensuring that adequate fluid and blood replacement has been accomplished, an infusion of norepinephrine (Levophed) may be necessary to treat hypotension. Propranolol hydrochloride (Inderal) and lidocaine hydrochloride (Xylocaine) may be needed to control tachycardia and cardiac arrhythmias.

The surgeon must first be aware of the anatomic differences of the two adrenal glands (see Plate 146, Figure 2). The left adrenal is in proximity to the aorta medially, the renal vein inferiorly, and the superior pole of the left kidney. It may be located near the renal hilum. Its main arterial supply comes directly from the aorta (12), but the main left adrenal vein (6) usually comes from the left renal vein (8). In contrast, the right adrenal is close to the superior pole of the kidney, the vena cava medially, and the right lobe of the liver superiorly. Its main arterial supply comes directly to its medial edge from the aorta (12), and the main right adrenal vein (5) comes directly from the inferior vena cava in a parallel manner. Both adrenal glands, however, have many arterial twigs from both the inferior phrenic arteries (9 and 10) and both renal arteries. Both adrenal glands are within gerota's fascia.

An adjustable vacuum beanbag should be placed on the operating table prior to bringing the patient into the room. The patient is positioned with the bag being at the level of their flank below the ribs and above the iliac crest over the break position of the table so as to allow a “jack knife” extension that may be useful in obese patients.

For a left adrenalectomy the patient is placed in a lateral position with the left arm crossing the chest and supported on a padded arm board (Figures 1A and 1B). The right arm is placed on a separate arm board and an axillary roll is used. Liberal padding is used between and around both arms. The abdomen and flank area should be exposed and the left knee flexed, with a padding of blankets or pillows between the legs.

The patient's hair should be removed with electric hair clippers with minimal trauma to the skin.

For a left adrenalectomy the surgeon stands on the patient's right side (Figure 1A). The camera operator stands to the left of the surgeon and the assistant on the left side of the patient. A 10-mm 30-degree laparoscope is placed either above the umbilicus or in the left lateral midsubcostal position in the mid-clavicular line just above the level of the umbilicus using the open technique of Hasson as described in Plate 91. The abdominal space is inflated to 15 cm of pressure, the laparoscope is introduced, and all four quadrants of the abdomen are examined for abnormalities, safety of other planned port sites, and evidence of any metastatic disease. A 5-mm port is placed in the far left lateral subcostal position and a 5-mm port is placed just to the left of the midline through the upper rectus muscle sheath just to the left of the round ligament. This reduces the chance of lacerating the epigastric artery, which might require suture ligation. These ports are in a line about two fingerbreadths or so below the edge of the costal margin. A third 5-mm port is placed in the anterior axillary line midway between the costal margin and the iliac crest (Figure 1B).

The operative exposure of the left adrenal is shown first. The splenic flexure of the colon is mobilized using an ultrasonic device so as to expose the kidney. The dissection is continued cephalad and the lesser sac is entered by separating the greater omentum from the splenic flexure and transverse colon (Figure 2). It is not necessary to mobilize the spleen. The lesser sac is entered and the pancreas identified (Figure 2). The retroperitoneun is exposed to show the kidney and posterior surface of the pancreas (Figures 2 and 3). Gerota's fascia is incised and opened to expose the upper pole of the kidney (Figures 2 and 3). Dissection is continued under gerota's fascia while the assistant lifts the tail of the pancreas anteriorly (Figure 3). This dissection should be continued as far cephalad as possible. The inferior pole of the adrenal gland will be seen as a bright yellow organ and the adrenal tumor exposed (Figure 3). It may be difficult to identify in obese patients with excessive retroperitoneal fat. If one cannot identify the left adrenal, it is usually because the operative field is too caudad and more superior dissection is needed. In these cases, identifying the left renal vein will allow the identification of the left adrenal vein that may be traced to the adrenal gland (Figure 3). It is usually necessary to place a retractor device under Gerota's fascia and the tail of the pancreas in order to expose the operative field (Figure 3).

Once the gland is identified, dissection is begun with the ultrasonic device along the inferior pole working medially. The adrenal vein is dissected with a Maryland dissector so as to visualize its entire circumference. It is doubly clipped on the patient side using a 5-mm clip applier (Figure 4). The vein is cut sharply leaving a longer stump on the renal vein side. The ultrasonic device is used to dissect around the adrenal gland beginning medially. Clips may be used to secure prominent blood vessels (Figures 5 and 6). The ultrasonic dissector effectively seals small arterial vessels that enter the adrenal gland like the spokes of a wheel. In some patients it is necessary to dissect the entire lateral border of the adrenal gland in order to mobilize it and retract the gland superiorly, thus permitting identification of the adrenal vein. The inferior attachments are divided. Finally the avascular lateral and superior attachments are dissected (Figure 7). The gland is now free for extraction in a laparoscopic retrieval bag (Figure 8). The technique for extraction is described under laparoscopic right adrenalectomy (see Plate 149).

The tumor bed is then inspected for any evidence of bleeding and any additional hemostasis obtained. The retraction on the pancreas is released and it is returned to its normal position.

If the patient does not have a pheochromocytoma, the orogastric tube and Foley catheter are removed in the postoperative recovery area. Intravenous fluids are administered and a clear liquid diet is ordered. Antibiotics are discontinued within 24 hours. Vital signs are monitored every 4 hours. The hemoglobin is checked on postoperative day one and the diet advanced. The patient is discharged on postoperative day 2 to 3. If the patient has a pheochromocytoma, the patient will usually be in the ICU. Monitoring of urinary output with a urinary Foley catheter is required. In addition blood pressure is monitored with an arterial line. The patient is transferred from the ICU when stable and the diet advanced. For patients with a functional tumor, discussion with the endocrinologist about resumption of preoperative medications is helpful.