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https://t.me/med1917
A. Papachristos and S. B. Sidhu
5 Postoperative Care
DVT prophylaxis continues post-operatively, including pharmacological and
mechanical measures combined with early mobilization.
Patients should be observed closely for signs of bleeding and adrenal insufciency in the immediate post-operative period. It is our practice to routinely check
the morning cortisol on the rst post-operative day and prescribe supplemental steroids if this level is low. Patients with pre-existing Cushing’s syndrome are empirically treated with IV hydrocortisone and undergo a slow post-operative steroid
wean, guided by the endocrinologist.
The urinary catheter can usually be removed on the rst postoperative day. Diet
is usually introduced on the rst post-operative day, however patients should be
monitored for ileus, particularly after the more extensive colonic mobilization
required in left open adrenalectomy.
Patients are usually able to leave the hospital after pain is adequately controlled
with oral analgesia and they are tolerating a normal diet.
References
1. Birtwistle L, Leong D, Aniss A, etal. Minimally invasive adrenalectomy: a cohort study of
surgical approach and outcomes. ANZ J Surg. 2023;93:2222–8. https://doi.org/10.1111/
ans.18443.
2. Miller BS, Gauger PG, Hammer GD, etal. Resection of adrenocortical carcinoma is less com-
plete and local recurrence occurs sooner and more often after laparoscopic adrenalectomy than
after open adrenalectomy. Surgery. 2012;152(6):1150–7.
3. Fassnacht M, Assie G, Baudin E, etal. Adrenocortical carcinomas and malignant phaeochro-
mocytomas: ESMO–EURACAN Clinical Practice Guidelines for diagnosis, treatment and
follow-up. Ann Oncol. 2020;31(11):1476–90.
4. Chui JN, Papachristos AJ, Mechera R, etal. Unexpected deaths after endocrine surgery: learning
from rare events using a national audit of surgical mortality. Br J Surg. 2022;109(11):1164–71.
5. Gaujoux S, Mihai R, Carnaille B, etal. European Society of Endocrine Surgeons (ESES) and
European Network for the Study of Adrenal Tumours (ENSAT) recommendations for the surgi-
cal management of adrenocortical carcinoma. Br J Surg. 2017;104(4):358–76.
6. Kebebew E.Adrenal incidentaloma. N Engl J Med. 2021;384(16):1542–51.
7. Sinclair TJ, Gillis A, Alobuia WM, etal. Surgery for adrenocortical carcinoma: when and how?
Best Pract Res Clin Endocrinol Metab. 2020;34(3):101408.
Laparoscopic Adrenalectomy:
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Transperitoneal Approach
StephanieChan andJamesA.Lee
1 Indications [1–3]
In well selected cases, laparoscopic adrenalectomy has become the treatment of
choice for adrenal tumors due to factors such as decreased postoperative pain and
faster recovery. Indeed, the majority of adrenalectomies in high volume centers are
performed laparoscopically. Indications for an adrenalectomy, whether open or laparoscopic, include a functional tumor, growth of an adrenal mass of 0.5cm in
6months based on imaging, adrenal tumor greater than 3–4 cm (since the risk of
adrenal carcinoma increases with increasing tumor size), and isolated metastatic
disease. The indications for laparoscopic adrenalectomy are essentially the same as
those for open adrenalectomy with the notable exception of adrenocortical cancer,
malignant pheochromocytoma, and large metastases. However, as skill and experience with laparoscopy increases, many clinicians have advocated for laparoscopic
adrenalectomy even for malignant disease. Contraindications for laparoscopic adrenalectomy also include general contraindications to laparoscopic procedures such
as severe cardiopulmonary risk and coagulopathy.
S. Chan · J. A. Lee (*)
Department of General Surgery, NewYork-Presbyterian Hospital, Columbia University
Medical Center, New York, NY, USA
Section of Endocrine Surgery, NewYork-Presbyterian Hospital, Columbia University
Medical Center, New York, NY, USA
e-mail: sjc2242@cumc.columbia.edu; jal74@cumc.columbia.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_8
69© The Author(s), under exclusive license to Springer Nature
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S. Chan and J. A. Lee
2 Preoperative Preparation [1–3]
Upon discovery of an adrenal mass, the two main goals are to (1) determine if it is
functional and (2) determine the risk of malignancy. History and physical exam
may provide useful clues as to whether a tumor is functional, but biochemical
interrogation is mandatory. If the tumor is non-functional, the next task is to determine the risk for cancer. If a patient is found to have an adrenal mass and has a
primary tumor elsewhere, he/she should be suspected of having metastatic disease.
Patients with adrenal incidentalomas, however, should undergo age- and risk factor-appropriate screening. Aside from the presence of local invasion, the best indication of risk for adrenocortical carcinoma is tumor size. Based on size, the risk for
adrenocortical cancer is approximately: less than 3% for tumors smaller than 4cm,
7% for tumors 4–6cm, and 25% or greater for tumors larger than 6cm. The following biochemical evaluation should be performed for the workup for adrenal tumors.
1. 24-h urine metanephrines or plasma metanephrines: Pheochromocytoma
2. 24-h urine cortisol, midnight salivary cortisol, or low dose dexamethasone sup-
pression test: Cushing’s syndrome
3. Plasma aldosterone and renin: Primary hyperaldosteronism
4. Cross-sectional imaging (CT or MRI): Localization and operative planning
5. CXR, colonoscopy, mammogram as appropriate: Metastatic disease workup
6. Free testosterone, estradiol, dehydroepiandrosterone: Virilizing func-
tional tumors
7. Urinary 5-HIAA, octreotide scan: Carcinoid
Preoperative preparation for patients depends largely upon the pathology encountered. For most adrenal tumors, no special precautions are needed. However, with
pheochromocytoma and Cushing’s syndrome, specic measures are needed due to
the tumor pathophysiology. For pheochromocytoma, preoperative alpha-blockade
with repletion of intravascular volume is crucial to a safe and successful operation.
Although phenoxybenzamine was the classic agent used for alpha blockade, recent
research has shown that selective alpha blockers (e.g. doxazosin, prazosin, and
terazosin) have largely replaced it without adverse clinical outcomes [4]. Once the
patient is adequately alpha-blocked and volume resuscitated, a beta-blocker may be
started if the patient is tachycardic. Starting a beta-blocker prior to alpha-blockade
may lead to unopposed alpha-mediated vasoconstriction that could precipitate a
hypertensive crisis. In addition, it is essential that the anesthesiologist utilize shortacting pharmacologic agents to combat hyper- or hypotension. For patients with
Cushing’s syndrome, a stress dose of steroids should be given prior to induction of
anesthesia. In addition, patients with Cushing’s syndrome should receive prophylactic antibiotics since they are more prone to infectious complications due to steroid excess.
Costal
Blankets
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3 Description ofProcedure
There are several approaches to laparoscopic adrenalectomy: transabdominal (lateral and anterior) and retroperitoneal (lateral and posterior). The duration of operating time is proportional to the experience of the operating surgeon with both general
laparoscopy and laparoscopic adrenalectomies. The laparoscopic lateral transabdominal adrenalectomy is currently the most common approach. However, some
single-institution observational studies have found the laparoscopic retroperitoneal
approach to have several advantages including shorter operative times, fewer complications (such as hernia), less postoperative pain, and shorter duration of hospital
of stay [5]. Large meta-analyses and randomized studies have demonstrated that
either approach may be performed safely and effectively without difference in morbidity or mortality [6–8]. The following description is of the laparoscopic lateral
transabdominal approach.
3.1 Positioning (Fig.1)
Patient positioning is often the hardest and most time consuming part of the operation. Constant communication with the anesthesiologists and staff is critical to prevent mishaps. Insert the urinary catheter and gather all necessary positioning
equipment prior to moving the patient. The patient should be placed on a beanbag
in the lateral decubitus position with the side of the adrenal tumor up. It is important
3
Fig. 1 This gure illustrates the proper decubitus positioning for a laparoscopic transabdominal
adrenalectomy. It is very important to ensure that the inferior costal margin is positioned at the
“break” in the operating table. (Used with permission of COACHsurgery.com)
21
Bean
bag
margin
Axillary
roll
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Assistant
ab
t
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S. Chan and J. A. Lee
to situate the patient’s costal margin 2–3cm superior to the point where the operating table exes. Positioning here places the junction of the superior pole of the
kidney and the adrenal gland at the break in the operating table, allowing gravity to
auto-retract the kidney inferiorly. The table should be exed maximally to increase
the space between the costal margin and the hip and thereby create more working
space. In addition, a kidney rest should be elevated to further accentuate this space.
The beanbag should be inated, taking care to not push it into the abdomen, as this
will decrease the intra-abdominal working space. Rather, the beanbag should conform to the patient’s hip and chest to ensure secure positioning. The arms should be
placed in an ergonomic position that does not apply tension to the shoulder joints.
Arms are most often separated by pillows rather than an arm board. All pressure
points should be adequately padded and an axillary roll should be placed too.
Pillows should be added between the legs in the usual decubitus positioning.
3.2 Port Placement (Fig.2a, b)
We typically enter the abdomen via a Veress needle technique at Palmer’s point
2–3cm inferior to the costal margin at the midclavicular line. On the left side, we
place three to four ports subcostally about 5–10cm apart, with the lateral-most port
in the midaxillary line. On the right side, a total of four ports are placed, with the
additional port for a liver retractor. When inserting the ports, it is important to enter
obliquely so the trocars are pointed toward the adrenal gland, otherwise the surgeon
Scope
Grasper
Ligasure
IIiac crest
Grasper
IIiac crest
Fig. 2 (a) Illustrates the placement of the ports for a laparoscopic transabdominal left adrenalectomy. Three to four ports are used in a left adrenalectomy. (Used with permission of COACHsurgery.
com). (b) Illustrates the placement of the ports for a laparoscopic transabdominal right adrenalectomy. In this case, the fourth port is used to place a liver retractor. (Used with permission of
COACHsurgery.com)
5/10mm port
placement
Assistan
Scope
Ligasure
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will have to work against the abdominal wall for the entire case. The camera is
placed in the middle port, and the surgeon works with a two-handed technique.
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4 Procedure
Although some authors advocate identifying and ligating the adrenal vein rst, we
do not adopt this strategy for the following reasons: (1) identifying the vein can be
difcult early on, especially in obese patients; (2) after ligating the vein in cases of
pheochromocytoma, the friable parasitic blood vessels characteristic of that disease
dilate and lead to increased bleeding. The key to performing this operation successfully is respecting and exploiting the clear planes between structures. For this reason, we use the hook cautery as a very precise means of following these planes. A
vessel-sealing device is utilized to coagulate and ligate vessels. The operation is
divided into a series of steps popularized by Quan-Yang Duh at UCSF:
1. Opening the book—Incising the peritoneum and Gerota’s fascia to separate the
adrenal gland and peri-adrenal fat from surrounding structures medially
2. Reading from the top down—Opening the plane between the adrenal gland and
peri-adrenal fat and the medial structures starting from the peri-adrenal fat tail
superiorly and moving to the adrenal vein or renal hilum
3. Identifying and ligating the adrenal vein
4. Separating the adrenal gland from the superior pole of the kidney
5. Freeing the rest of the peri-adrenal attachments
4.1 Left Adrenalectomy
First, mobilize the splenic exure by incising the lienorenal (splenorenal) and lienophrenic (splenophrenic) ligaments to allow the spleen to fall medially with gravity.
Using the hook cautery, stay 1cm off the splenic capsule to prevent tearing of the
capsule. Incise the ligament at the superior pole of the spleen. At this point, it is
important to identify and avoid the stomach, which lies just posteriorly. Once the
spleen is dissected and reected medially, the plane between Gerota’s fascia and the
pancreas becomes readily identied. Retract the spleen medially to accentuate this
plane. In obese patients, a fourth port for lateral retraction of the kidney and adrenal
is sometimes helpful. The plane between Gerota’s fascia and the pancreas is carried
inferiorly (Fig.3).
The splenic exure often needs to be mobilized as you come to the superior pole
of the kidney. Once the plane between spleen and Gerota’s fascia is developed, open
Gerota’s fascia superiorly and dissect through the peri-adrenal fat to identify the
psoas muscle. Carry this dissection laterally 4–5cm to allow for lateral and inferior
retraction of the adrenal gland as necessary. Then divide the peri-adrenal fat along
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Fig. 3 This gure
illustrates the line of
dissection between the
pancreas/spleen and the
left adrenal gland
Fig. 4 This gure
demonstrates the relative
anatomy of the inferior
phrenic vein joining the
left adrenal vein. The
common trunk then drains
into the left renal vein
S. Chan and J. A. Lee
the medial edge of the adrenal gland and carry this dissection toward the renal
hilum. Multiple adrenal arteries will be identied and may be ligated with the electrocautery or vessel-sealing device as suitable. During this dissection, the phrenic
vein is often encountered and will lead to the adrenal vein (Fig.4).
Another rule of thumb is that the splenic vessels “point” to the location of the
adrenal vein. The adrenal and phrenic veins are dissected with careful blunt dissection and ligated either with clips or the vessel-sealing device. Once the vessels are
divided, identify the plane between the superior pole of the kidney and adrenal
gland. When carrying out this dissection, it is important to watch out for a superior
pole renal artery and avoid injuring it. The adrenal gland is then separated from the
kidney. Then using a combination of blunt and sharp dissection, the adrenal gland is
liberated from the psoas muscle and lateral abdominal wall. Hemostasis is obtained
with irrigation, aspiration, and electrocautery. The specimen is then removed in an
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impermeable specimen bag through the most anterior trocar. Enlarging the incision
may occur for larger specimens. Fascial and skin incisions are closed.
4.2 Right Adrenalectomy
First, divide the triangular ligament and the lmy attachments in the bare area of the
liver to fully mobilize the lateral portion of the liver medially. The inferior leaet of
the ligament will transition into the peritoneum and Gerota’s fascia, which is divided
carefully up to the lateral edge of the inferior vena cava. The dissection is then carefully carried along the lateral edge of the inferior vena cava. Once the Gerota’s
fascia, peritoneum, and triangular ligaments are widely incised, mobilize the
Fig. 5 The “V” illustrates
the technique of creating a
plane between the adrenal
gland and liver moving
from superior to inferior.
The liver is being retracted
anteriorly and medially to
expose the anterior surface
of the adrenal gland
Fig. 6 This gure
demonstrates the relative
anatomy of the right
adrenal vein, which enters
the adrenal gland
anteriorly. The right
adrenal vein is relatively
short and comes directly
off of the inferior vena
cava (IVC) into the adrenal
gland/tumor
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S. Chan and J. A. Lee
superior peri-adrenal fat pad as with the left side. Dissection is carried along the
medial edge of the adrenal gland as described with the left adrenalectomy (Fig.5).
Typically a single, short adrenal vein enters the adrenal gland and inferior vena
cava at the midpoint of the gland (Fig.6). The vein is dissected free and divided
between clips or with the vessel-sealing device. The rest of the adrenalectomy proceeds as described for the left adrenalectomy.
5 Postoperative Care
A collaborative effort with the endocrinologists and general medical physicians is
important to successful postoperative care. Postoperative follow-up is based on the
particular pathology encountered and institutional requirements. The following are
general guidelines for follow-up care based on pathology:
1. Aldosterone-producing adenoma: Stop all aldosterone receptor antagonists and
potassium supplementation immediately after the operation. Anti-hypertensive
medications may be either stopped and added back as needed, or halved and
adjusted as needed. Check potassium levels once a week for 4weeks and support
with mineralocorticoids.
2. Cushing’s syndrome: A rapid steroid taper to a low dose of oral steroids should
be undertaken in conjunction with the endocrinologists. It is crucial to monitor
these patients closely for signs and symptoms of adrenal insufciency or
Addisonian crisis.
3. Pheochromocytoma: Patients must be monitored for hemodynamic instability,
especially hypotension. Postoperative hypotension should be treated with volume resuscitation. The need for monitoring in the ICU has decreased dramatically with proper preoperative preparation. Repeat cross-sectional imaging and
plasma metanephrines should be obtained in 6months to rule out recurrent or
metastatic disease.
4. Adrenocortical cancer: Patients should be considered for enrollment in a clinical
trial or placed on adjuvant chemotherapy such as mitotane. Repeat crosssectional imaging should be obtained in 3months to rule out recurrent or metastatic disease.
References
1. Tada HTDS, Lee JE.Adrenal tumors. In: Wilkins LW, editor. The M.D. Anderson surgical
oncology handbook. Houston: Lippincott Williams & Wilkins; 2003.
2. Gagner M, Assalia A.Laparoscopic adrenalectomy. In: Saunders E, editor. Textbook of endo-
crine surgery. Philadelphia: Elsevier; 2005. p.647–62.
3. Swanstrom LL.Laparoscopic adrenalectomy. In: Cameron JL, editor. Current surgical therapy.
11th ed. NewYork: Elsevier; 2014.
Laparoscopic Adrenalectomy: Transperitoneal Approach
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4. Kuo EJ, Chen L, Wright JD, McManus CM, Lee JA, Kuo JH. Phenoxybenzamine is no longer
the standard agent used for alpha blockade before adrenalectomy for pheochromocytoma: a
national study of 552 patients. Surgery. 2023;173(1):19–25.
5. Chen W, Li F, Chen D, Zhu Y, He C, Du Y, Tan W. Retroperitoneal versus transperitoneal
laparoscopic adrenalectomy in adrenal tumor: a meta-analysis. Surg Laparosc Endosc Percutan
Tech. 2013;23(2):121–7.
6. Constantinides VA, Christakis I, Touska P, Palazzo FF.Systematic review and meta-analysis
of retroperitoneoscopic versus laparoscopic adrenalectomy. Br J Surg. 2012;99(12):1639–48.
7. Nigri G, Rosman AS, Petrucciani N, Fancellu A, Pisano M, Zorcolo L, Ramacciato G, Melis
M.Meta-analysis of trials comparing laparoscopic transperitoneal and retroperitoneal adrenal-
ectomy. Surgery. 2013;153(1):111–9.
8. Mohammadi-Fallah MR, Mehdizadeh A, Badalzadeh A, Izadseresht B, Dadkhah N, Barbod
A, Babaie M, Hamedanchi S. Comparison of transperitoneal versus retroperitoneal laparo-
scopic adrenalectomy in a prospective randomized study. J Laparoendosc Adv Surg Tech
A. 2013;23(4):362–6.
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