There are a few general recommendations that reduce the difficulty of laparoscopic adrenalectomy. First, any bleeding substantially impairs visualization. Dissection should be gentle and every act of tissue division accompanied by a hemostatic maneuver. Second, irrigation to remove obscuring blood cannot be reliably evacuated. Irrigation generally should not be used, as it tends to accumulate and obscure the bed of dissection. Third, removal of blood by suction tends to collapse the operative field and lead to tedious adjustment of retraction. For these reasons, small neurosurgical patties or rolled Kitner sponges are the best way to remove blood and to control minor bleeding. The use of instruments with hemostatic capability, such as ultrasonic shears or bipolar vessel sealing devices, should be used. Fourth, manipulation of instruments through the most lateral port is impaired by patients with wide hips. Port sites should be placed at least 7 cm apart to avoid limitations from instrument crowding. Thus the details of the patient's position and the placement of the ports are not routine and should not be delegated. Finally, the adrenal itself cannot be gripped and retracted directly without rupture and bleeding. Retraction should be performed by leaving periadrenal fat strategically attached to the adrenal and gripping the fat or by elevation of the adrenal from beneath. The specimen side of the adrenal vein after ligation can also be used as a handle for retraction. Otherwise, a rolled Kitner sponge held with a grasper can provide gentle and effective traction.
As in all operations, patient positioning and exposure are critical to the success of the laparoscopic adrenalectomy. For the lateral transperitoneal approach, the lateral decubitus position favors retraction of the abdominal viscera by gravity and facilitates exposure of the adrenal gland (Fig. 63-1). In obese patients, it may be a useful position for the anterior border of the patient's body near the edge of the bed and may allow the abdominal pannus to hang over the edge. The surgical table should be flexed with the center of the break in the table located approximately at the midpoint between the costal margin and the iliac crest to facilitate the greatest exposure. Exposure can be improved by raising a kidney rest. Care should be taken during flexion in the elderly and in patients with spine disease. The patient should be secured to the table, an axillary roll placed, and all pressure points should be adequately protected.
Optimal positioning of patient for a left laparoscopic adrenalectomy in the lateral decubitus position. The midabdomen is placed over the break in the table to optimize trunk extension and reduce interference with instrument movement by the iliac crest. The anterior abdominal wall should not be compressed.
Selection of the appropriate instruments can greatly facilitate visualization, exposure, and dissection. A high-definition video camera and monitors in conjunction with a 30-degree laparoscope provides the best visualization of the operative field. Fan retractors provide excellent exposure with the least risk of injury to the liver and spleen. Other essential equipment includes blunt dissectors, an endoscopic clip device, a laparoscopic bag, Kitner sponges, and a hook electrocautery. Laparoscopic devices, such as the Harmonic scalpel (Ethicon, Cincinnati, OH) or LigaSure (Valleylab, Boulder, CO), are useful and likely decrease operation times.
Right Laparoscopic Adrenalectomy
The patient is placed in the left lateral decubitus position, and the surgeon marks four-port sites along the right costal margin from the xiphoid to the midaxillary line (Fig. 63-2). Either a Veress needle entry or a muscle splitting open entry can be used to gain access to the peritoneal cavity. After insufflation of the peritoneal cavity and placement of additional ports under direct vision, the fan retractor is placed in the most medial port and the camera is placed in the second most medial port. Figure 63-3 shows the initial view of the right upper quadrant after entry is achieved. The hepatic flexure of the colon is freed from its attachments and allowed to retract inferomedially from gravity. The fan retractor initially retracts the right lobe of the liver in the medial direction, and the right triangular ligament is taken down with a hook electrocautery. This mobilization enables superior and anterior retraction of the right lobe of the liver, which uncovers the retroperitoneum near the adrenal gland (Fig. 63-4). In most cases, the kidney, periadrenal fat, and IVC are visible after this maneuver.
Port placement for a right laparoscopic adrenalectomy. In this example, abdominal entry is gained under direct visualization through the most medial site.
Initial view of right upper quadrant in a right laparoscopic adrenalectomy. The arrow indicates the direction of liver retraction from the epigastric port.
View during right laparoscopic adrenalectomy with the liver retracted from the epigastric port. Some attachments of the right lobe of the liver to the diaphragm have been divided. The dotted line indicates the line of further peritoneal incision to mobilize the right lobe of the liver from the diaphragm.
We begin the dissection in the superolateral border of the periadrenal fat with a hook electrocautery. This exposes the diaphragm posteriorly, and the dissection is carried out in the medial direction along the superior border of the periadrenal fat (Fig. 63-5). A few small arteries are typically located in this area, which can be controlled with electrocautery, clips, or a hemostatic device. Careful dissection with blunt graspers should be used while approaching the IVC, near the superomedial border of the periadrenal fat. After establishing the superomedial corner of the periadrenal fat, the dissection is carried down in the caudal direction between the IVC and periadrenal fat (Fig. 63-6). The adrenal vein typically resides near the top third of this medial border and approaches the IVC at approximately a right angle. After clip or stapler ligation of the adrenal vein, this medial plane of dissection opens significantly (Fig. 63-7). Some surgeons routinely divide the adrenal vein with the LigaSure device without the use of a clips or staples (Fig. 63-8).
View during right laparoscopic adrenalectomy after initial dissection to mobilize the right adrenal. The dotted line shows the peritoneal incision under the retracted liver that exposes the adrenal.
Dissection to expose the adrenal gland during right laparoscopic adrenalectomy.
Dissection to expose the adrenal vein during right laparoscopic adrenalectomy. The length of the right adrenal vein is exaggerated in this schematic.
View during right laparoscopic adrenalectomy after division of the right adrenal vein with clips. The dotted line indicates the line of resection to complete the adrenalectomy. Retraction underneath the adrenal at the site of the severed adrenal vein is often advantageous. The length of the right adrenal vein is exaggerated in this schematic.
At this point, the specimen side of the adrenal vein can be grasped for retraction. The inferomedial border of the dissection also requires careful blunt dissection, with special attention to avoid injuring the renal hilar vessels. The dissection is then carried laterally along the superior surface of the kidney. Special care must be taken to avoid accidental ligation of any arterial branches to the superior pole of the kidney. Once the plane of dissection is established between the inferior border of the periadrenal fat and the kidney, the only remaining attachments are posterior and lateral to the adrenal gland. A blunt grasper can be used to elevate the adrenal gland in the anterior direction, with special care to avoid disruption of the adrenal capsule. The remaining posterior and lateral attachments can be divided with a LigaSure or Harmonic scalpel device. The dissection should clear all fibrofatty and lymphatic tissue from the diaphragmatic surface. Once all attachments are divided, the gland is placed into an endoscopic bag for removal. If appropriate, the mouth of the bag can be exteriorized and the specimen can be morcellated and removed through a port incision. Otherwise, dilation of the fascia and skin are often required to remove the specimen en bloc.
Left Laparoscopic Adrenalectomy
The steps are the same as the right adrenalectomy, with a few differences that will be delineated. The patient is placed in the right lateral decubitus position and the surgeon marks three- or four-port sites along the costal margin from the xiphoid to the posterior axillary line (Fig. 63-9). Sometimes the fourth port is not needed, as the spleen retracts medially with gravity. After access and insufflation of the peritoneal cavity, the splenic flexure of the colon is taken down (Fig. 63-10). The left liver and spleen are mobilized from the diaphragm using hook electrocautery. With medial mobilization of the spleen, the retroperitoneum is exposed. The left kidney, periadrenal fat, and tail of the pancreas are often visualized at this point. The dissection begins in the superolateral corner and proceeds in the medial direction between the spleen and the superior border of the adrenal gland (Fig. 63-11). The splenic vessels are often in close proximity to this plane of dissection. Once the superomedial corner is reached, the tail of the pancreas and the inferior phrenic vein can often be seen. The appearance of the pancreas tail can be similar to the adrenal gland. The dissection continues in the inferior direction along the medial border. The left adrenal vein is often located in the inferomedial portion of the dissection. After adrenal vein ligation, the dissection continues along the inferior border between the adrenal gland and the kidney (Fig. 63-12). In a similar fashion to the right adrenalectomy, the remaining posterior and lateral attachments are divided flush to the surface of the kidney and diaphragm, and the adrenal tumor is removed in bloc with the surrounding periadrenal fat.
Port placement for left laparoscopic adrenalectomy in the right lateral decubitus position. In this example, initial abdominal entry is gained through a medial incision. A fourth port is often not required on the left.
View during left laparoscopic adrenalectomy, showing division of the peritoneum over the kidney and progressive detachment of the spleen from the left diaphragm.
View during left laparoscopic adrenalectomy. The spleen had been partially mobilized and is retracting to the right by gravity. The separation between the posterior pancreas and the anterior surface of the left adrenal had been developed. The left renal vein is exposed, as well as the takeoff of the left adrenal vein.
View during left laparoscopic adrenalectomy. The spleen is fully mobilized. The adrenal vein has been divided between endoclips. The dotted line indicates the line of resection.
Retroperitoneoscopic adrenalectomy involves directly accessing the retroperitoneal space from the posterior approach. This does not entail entrance into the peritoneal cavity, and therefore it is not laparoscopic surgery. Unlike laparoscopic adrenalectomy, the retroperitoneoscopic approach does not require mobilization of peritoneal organs (e.g., liver, spleen, colon). Furthermore, the surgeon can access both adrenal glands from the same position, which minimizes operative time during bilateral adrenalectomy. Retroperitoneoscopic adrenalectomy is particularly useful for patients with intraperitoneal adhesions from previous laparotomy and is most suitable for small lesions positioned well above the renal hilum that do not have radiographic evidence of local invasion.
First, the patient is intubated, and all tubes and lines are placed in the supine position. Then the patient is flipped into the prone position, with the hips and knees flexed. This positioning requires the use of bolsters across the chest and hips, as well as sufficient padding for the face, arms, and knees. The abdomen should hang down between the two transversely positioned bolsters.
A small transverse incision is made just caudal to the tip of the 12th rib, and sharp dissection is used to dissect through the subcutaneous tissues and deep fascia. The length of this incision should be around 1.5 cm, which should be enough to accommodate the surgeon's index finger. Digital examination with the index finger can be used to confirm that the dissection is through the deep fascia, and it allows palpation of the smooth underside of the ribs. A second lateral 5-mm port is placed at near the midaxillary line at the same craniocaudal level under direct palpation using the index finger as a guide through the first incision. Then a third 5-mm port is placed similarly under digital palpation, just lateral to the paraspinous muscles at the same craniocaudal level. This medial port should be approximately 3 or 4 cm caudal to the lowest rib.
Then a 12-mm balloon port is placed in the middle incision to ensure that an airtight seal and the space are insufflated to a pressure of 20–30 mm Hg. A 30-degree 10-mm scope is placed in the middle trocar with the angle toward the ceiling. A blunt grasper is used though the lateral port to dissect through Gerota's fascia. Using blunt dissection, the tissues around the medial and lateral ports are cleared and space is created posterior to kidney and adrenal gland. Usually, the paraspinous muscles can be seen medially. With some blunt dissection, the peritoneal lining can be visualized laterally. At the floor of the dissection (anterior), careful blunt dissection can be used to visualize the kidney.
Dissection is carried along the superior border of the kidney, from lateral to medial to separate the top of the kidney from periadrenal fat. Usually during this portion of the dissection, the adrenal gland itself becomes evident through the periadrenal fat. On the right side, the IVC is found anterior and medial to the inferomedial border of the periadrenal fat. The adrenal vein is usually anterior and thus can be difficult to visualize. Division of the adrenal vein can be done with a LigaSure device with or without clips. The specimen side of the adrenal vein can be used to retract the adrenal gland in the cephalad and posterior dissection. The remaining attachments between the periadrenal fat anteriorly and superiorly can be divided with a LigaSure device or electrocautery. As with laparoscopic adrenalectomy, the small adrenal arteries can be controlled with either hook electrocautery or a hemostatic device; clips are usually not required. Small holes in the peritoneum are of no significant consequence and do not require repair. Removal of the specimen can usually be achieved without morcellation or extension of the incision. Closure of the deep fascia in the middle incision usually requires only a single simple nonabsorbable suture. Hernia through these posterior incisions is uncommon.