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Laparoscopic Adrenalectomy:
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Retroperitoneal Approach
CameronD.Adkisson andLinwahYip
1 Introduction
Laparoscopic adrenalectomy has become the gold standard for removal of nonmalignant tumors of the adrenal gland since its introduction by Gagner in 1992
[1–3]. Advantages of the laparoscopic approach include decreased pain and expedited recovery. Indications for adrenalectomy have been reviewed elsewhere and
include either the presence of a functional tumor of the adrenal cortex or medulla,
or clinical concern for malignancy such as an adrenal nodule that demonstrates
interval growth, is ≥4cm in size, or has concerning features on imaging. Isolated
metastatic disease in patients who may benet from metastasectomy is a less common indication for adrenalectomy.
Posterior retroperitoneoscopic adrenalectomy is an alternative approach to
total or partial adrenalectomy, and has demonstrated utility, safety and efcacy in
a variety of adrenal tumors including aldosteronomas, cortisol-secreting tumors,
pheochromocytomas, virilizing tumors, benign adenomas, angiomyolipomas,
ganglioneuromas, and adrenal metastases [4–6]. First reported in 1995 by Mercan
etal., the posterior retroperitoneoscopic approach was not widely adopted until
the necessary increased insufation pressures for improved visualization were
C. D. Adkisson
Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh,
Pittsburgh, PA, USA
L. Yip (*)
Division of Endocrine Surgery, University of Pittsburgh School of Medicine,
Pittsburgh, PA, USA
Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
e-mail: yipl@upmc.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_9
79© The Author(s), under exclusive license to Springer Nature
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C. D. Adkisson and L. Yip
deemed safe for patients [7]. Giebler et al. clearly demonstrated that impaired
cardiac lling occurred only when peritoneal insufation pressures exceeded
15mmHg, but did not occur when retroperitoneal insufation pressures exceeded
15mmHg [8].
The retroperitoneoscopic approach to the adrenal gland offers distinct advantages to the transperitoneal approach including direct exposure of the adrenal gland
and adrenal vein, avoidance of intraabdominal adhesions, and avoiding the need for
adjacent organ displacement including the spleen, colon, and liver. Finally, bilateral
adrenalectomies for ACTH-dependent Cushing’s or familial pheochromocytoma
can be performed through a retroperitoneal approach without patient repositioning.
Walz etal. described 560 adrenalectomies in 520 patients utilizing the retroperitoneoscopic approach during a 12year period with no reported mortalities, a major
complication such as myocardial infarction, bleeding requiring transfusion, and
pneumonia occurring in 1.3%, and a conversion rate to open or lateral approach of
only 1.7% [4]. Furthermore, they observed improved operative efciency with cases
performed at a mean of 40min by the end of their study period [4]. The retroperitoneoscopic approach should be used with caution in patients with (1) severe lung
disease or COPD, (2) inadequate working space determined by the distance from
the posterior 12th rib margin to the superior border of the iliac crest, (3) suspected
adrenocortical cancer or suspected invasion into surrounding structures, (4) inability to tolerated the prone positioning, and (5) high BMI (i.e. > 45). Larger adrenals
≥6 cm should also be approached with caution through a retroperitoneoscopic
approach as the malignancy rate is higher and the ability to manipulate large tumors
in the retroperitoneal space is limited. Choice of operative approach should be
guided by surgeon, patient, and tumor specic variables [6].
Other groups have described their successful experience with the posterior
approach as well. In Perrier etal. 68 patients had retroperitoneoscopic adrenalectomy with a low conversion rate of 9%, a mean operating time of 121min, and no
mortalities [5]. The feasibility and safety of the procedure in obese patients (BMI
≥30) has been reported with decreased operative time and blood loss for retroperitoneoscopic compared to transperitoneal adrenalectomy [9]. Partial or corticalsparing adrenalectomy is also feasible and safe through the retroperitoneoscopic
approach [10, 11]. In a large retrospective cohort analysis of surgical registry data
comparing adrenalectomy by the laparoscopic transperitoneal approach (n=1696
patients) to the retroperitoneoscopic approach (n=964), there were no differences
in conversion rates to open, morbidity, wound complications, reoperation, or readmission rates between the 2 groups. Length of hospital stay was shorter with the
retroperitoneal approach [12]. Similar ndings were seen in a meta-analysis comparing 12 studies and 775 patients and in addition to shorter length of hospital stay,
less blood loss and shorter time to oral intake was associated with the retroperitoneoscopic compared to the laparoscopic transperitoneal adrenalectomy, with no differences identied in the rates of major complications, operative time, or conversion
to open [13].
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2 Preoperative Preparation
The pre-operative planning for patients having retroperitoneoscopic adrenalectomy
is the same as that for the transperitoneal approach [6]. Prior to surgery, the planned
approach and tumor functional status is discussed with the anesthesia and operating
room teams. An operating room table is ready and available immediately outside the
operative suite during all retroperitoneoscopic adrenalectomies in preparation for
emergent open laparotomy if necessary.
3 Description ofProcedure
3.1 Positioning
Retroperitoneal adrenalectomy can be performed either using robotic-assistance or
laparoscopically [14]; the following will focus on the laparoscopic approach.
Similar to preparing for laparoscopic transperitoneal adrenalectomy, patient positioning can sometimes be difcult and time-consuming. While the patient is supine
on the transporting gurney, general anesthesia with endotracheal intubation, foley
catheter and needed IV access including central and arterial lines are placed before
prone positioning on the operating table. We frequently inform anesthesia about the
potential for CO2 retention and request mild hyperventilation after intubation to
decrease CO2 levels before positioning. This is particularly helpful in obese patients
or those with COPD as they can have a higher degree of CO2 retention which may
cause challenges with intraoperative hemodynamic instability and extubation. The
patient is then rotated into a prone jackknife position. We use a modied table with
a thin gel pad placed in the lower ½ of the bed instead of the typical operating table
padding, and large gel rolls that are positioned under the breasts and across the
pubic symphysis to maximize the working space which is dened as the 12th rib
posteriorly to the superior border of the iliac crest on the ipsilateral side (Fig.1).
Fig. 1 Operating table
modied to facilitate
retroperitoneal approach
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The goal of padding placement is to allow the ventral abdominal wall to hang freely
anteriorly. A Cloward table saddle can also be used. The patient’s arms are extended
to 90° and placed on arms rests with padding in an ergonomic position to ensure no
tension on the shoulders or pressure on the cubital tunnel. Manipulation of the surgical table with Trendelenburg positioning and exing the hips to approximately 90°
further maximizes the working space. The patient’s legs are positioned without
pressure on the knees to avoid hip displacement. Two high-denition monitors are
placed on either side of the operating table. The ank is then prepared using
chlorhexidine or betadine, and draped with blue towels and standard operating
sheets from the lower border of the shoulder blades as far laterally as possible to the
medial portion of the gluteus maximus inferiorly.
C. D. Adkisson and L. Yip
3.2 Required Equipment
• Ports:
– 5mm bladeless trocar × 2
– 10mm disposable Balloon trocar (Autosuture)
– 5mm bladeless trocar × 1 (optional)
• Laparoscopic cameras:
– 10mm 30° scope
– 5mm 30° scope
– 5mm 45° scope (optional)
• Other Instruments:
– 5 mm LigaSure™ (Covidien Ltd, Manseld, MA) or Harmonic Ultrasound
Device® (Ethicon Endo-Surgery, Inc)
– Laparoscopic Suction/Irrigation
– Laparoscopic blunt grasper
– Laparoscopic peanuts
– EndoCatch™ (Covidien Ltd, Manseld, MA) for specimen extraction
3.3 Insufation
20–24mmHg CO2.
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3.4 Port Placement
An initial 1.5–2cm incision is made just beneath the tip of the 12th rib transversely
and will be used for initial camera placement and specimen extraction. Using a
combination of sharp and blunt dissection, the retroperitoneal space is entered.
Using the index nger to clear retroperitoneal fat off the postero-medial border
(paraspinous musculature) enables creation of a working space. This dissection then
is carried to the superior-most extent of the operator’s reach medially and inferiorly
until enough working space is created for placement of the camera port and the two
5mm trocars. A 5mm trocar is then placed 4–5cm laterally and 2cm inferior to the
tip of the 11th rib angled appropriately to avoid collision with the rib during instrument manipulation. We insert a nger through the initial incision to guide the trocar
into the working space and clear any overlying retroperitoneal fat. A second 5mm
trocar is placed at the medial border of the paraspinous muscles usually ~4 cm
medial to the 10mm trocar and 3–4cm below the 12th rib angled to 45°. The balloon trocar is placed through the initial incision and CO2 insufation is achieved to
20–24mmHg. The surgeon and assistant typically stand on the ipsilateral side of the
target gland.
4 Procedure
Using the 10mm 30° scope, additional working space in the retroperitoneum is rst
created using two peanuts/graspers in a sweeping motion. The paraspinous muscle
is an important landmark that allows for appropriate orientation in the retroperitoneum, and is rst identied and cleared as superiorly as possible towards the adrenal. Starting medially will also prevent entry into the peritoneum which lies laterally
and near the plane of dissection particularly in thin patients. Entering the peritoneum during the dissection is suboptimal as CO2 insufation into the peritoneal
cavity can cause progressive reduction of the retroperitoneal working space as the
peritoneal contents are displaced by the CO2. The superior border of the kidney is
then identied as the retroperitoneal fat is swept away. The upper pole of the kidney
is identied and Gerota’s fascia is sharply entered, aided by pushing the kidney
down with the surgeon’s opposite hand exposing the adrenal gland. Freeing up the
adrenal from the superior pole of the kidney is best accomplished at this point while
the adrenal is still attached superiorly and medially. Rarely, if exposure is limited, a
fourth 5mm trocar may be placed inferior to the lateral port to retract the kidney
during dissection of the inferior portion of the adrenal gland.
During right adrenalectomy, the adrenal vascular supply is encountered posterior
to the vena cava. Further dissection of the medial aspect of the adrenal gland facilitates gentle lateral retraction of the gland and clear visualization of the IVC.The
adrenal vein is then typically seen running posterior and lateral at 9–10 o’clock and
may be clipped or doubly ligated with the coagulation device (Fig.2). During left
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Fig. 2 Intraoperative
anatomy of right
retroperitoneoscopic
adrenalectomy. A adrenal
gland, AV adrenal vein, k
right kidney, VC inferior
vena cava. (Image from
Walz etal. [4], with
permission from Elsevier)
Fig. 3 Intraoperative
anatomy of left
retroperitoneoscopic
adrenalectomy. A adrenal
gland with adenoma, AV
adrenal vein, K left kidney.
(Image from Walz etal.
[4], with permission from
Elsevier)
C. D. Adkisson and L. Yip
adrenalectomy the adrenal vein is encountered running medial to the upper pole of
the kidney at approximately 4–5 o’clock and is clipped or doubly ligated with coagulation (Fig.3). An accessory renal artery may be present and is usually located in
the 6 o’clock position, and should be preserved. On the left, there is often a limb of
adrenal that extends anteriorly and medially into the renal hilum. Care should be
taken not to inadvertently transect the adrenal at this location.
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Once the vein has been divided, dissection is then carried out laterally, leaving
the superior attachments for last. The adrenal gland is then extracted through the
10mm port using an EndoCatch™ (Covidien Ltd, Manseld, MA). After extraction,
the specimen is always inspected carefully on the back table to ensure that the adrenal has been resected in total. The camera is then re-inserted to visualize the adrenal
bed for both adequate hemostasis and ensure complete resection. The balloon trocar
site fascia is then closed, port sites are reapproximated at the skin, and sterile dressing (either steristrips or surgical glue) is applied.
5 Postoperative Care
Subcutaneous crepitus may be evident but resolves rapidly. Standard management
of incisional pain is administered. Patients are given clear liquids after operation
and if well tolerated move quickly to regular diet. The majority of patients are discharged home on postoperative day 1 with follow up in 2–3weeks. Postoperative
follow-up and medication continuation or discontinuation is based on the functional
status of the lesion, and is similar to the approach after the laparoscopic transperitoneal approach. A multidisciplinary approach facilitates safe, timely discharge.
References
1. Gagner M, Lacroix A, Bolte E.Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med. 1992;327:1033.
2. Schlinkert RT, van Heerden JA, Grant CS, etal. Laparoscopic left adrenalectomy for aldosteronoma: early Mayo Clinic experience. Mayo Clin Proc. 1995;70:844–6.
3. Brunt LM.Minimal access adrenal surgery. Surg Endoscopy. 2006;20:351–61.
4. Walz MK, Alesin PF, Wenger FA, Deligiannis A, Szuczik E, etal. Posterior retroperitoneoscopic adrenalectomy—results of 560 procedures in 520 patients. Surgery. 2006;140:943–50.
5. Perrier ND, Kannamer DL, Bao R, et al. Posterior retroperitoneoscopic adrenalectomy:
preferred technique for removal of benign tumors and isolated metastases. Ann Surg.
2008;248:666–74.
6. Yip L, Duh QY, Wachtel H, etal. American Association of Endocrine Surgeons guidelines for
adrenalectomy: executive summary. JAMA Surg. 2022;157:870–7.
7. Mercan S, Seven R, Ozarmagan S, etal. Endoscopic retroperitoneal adrenalectomy. Surgery.
1995;118:1071–5.
8. Giebler RM, Behrends M, Steffens T, etal. Intraperitoneal and retroperitoneal carbon dioxide
insufations evoke difference effects on caval vein pressure gradients in humans: evidence for
the starling resistor concept of abdominal venous return. Anesthesiology. 2000;92:1568–80.
9. Epelboym E, Digesu C, Johnston MG, etal. Expanding the indications for laparoscopic retroperitoneal adrenalectomy: experience with 81 resections. J Surg Res. 2014;187:496–501.
10. Walz MK, Peitgen K, Diesing D, et al. Partial versus total adrenalectomy by the posterior
retroperitoneoscopic approach: early and long-term results of 325 consecutive procedures in
primary adrenal neoplasias. World J Surg. 2004;28:1323–9.
11. Grubbs EG, Rich TA, Ng C, et al. Long-term outcomes of surgical treatment for hereditary
pheochromocytoma. J Am Coll Surg. 2013;216:280–9.
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12. Van Den Heede K, Vatansever S, Girgin T, et al. Posterior retroperitoneal versus transperitoneal laparoscopic adrenalectomy in adults: results from the EUROCINE surgical registry.
Langenbecks Arch Surg. 2023;408:241.
13. Gavriilidis P, Camenzuli C, Paspala A, etal. Posterior retroperitoneoscopic versus laparoscopic transperitoneal adrenalectomy: a systematic review by an updated meta-analysis. World
J Surg. 2021;45:168–79.
14. Dickson PV, Alex GC, Grubbs EC, etal. Robotic-assisted retroperitoneoscopic adrenalectomy:
making a good procedure even better. Am Surg. 2013;79:84–9.
C. D. Adkisson and L. Yip
Part II
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Breast Surgery
Breast Conservation Surgery
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AstridBottyvan den Bruele andLauraH.Rosenberger
1 Introduction
The historic Halstead radical mastectomy was the standard of care for many decades.
William Halstead believed that breast cancer was a local disease at its onset and,
therefore, the extent of local resection should impact survival [1]. However, about
60% of women continued to die due to breast cancer, which called into question the
central dogma at the time. With this in mind, Bernard Fisher started the NSABP-04
trial, recognizing that perhaps breast cancer was not a local disease at its onset;
perhaps it was systemic. The trial was designed to determine whether less extensive
surgery (radical mastectomy vs. mastectomy alone) with or without radiation therapy (RT) was as effective as the Halstead mastectomy. At 25years of follow up, the
data demonstrated no difference in disease free survival (DFS), recurrence free survival (RFS), or overall survival (OS) when looking at the extent of local surgery
within these groups [2]. The results of this trial not only challenged the approach to
breast cancer treatment, but truly changed the surgical landscape as we know
it today.
Beginning in the mid-1970s, subsequent randomized trials in both the United
States and Europe began to emerge assessing whether excision of the cancer itself,
while maintaining the remaining unaffected breast tissue (breast conservation surgery), was an oncologically reasonable alternative to mastectomy. The results of
these trials demonstrated equivalence between mastectomy and breast conservation
A. B. van den Bruele (*) · L. H. Rosenberger
Department of Surgery, Duke University Hosptial, Durham, NC, USA
e-mail: ab958@duke.edu; astrid.botty.van.den.bruele@duke.edu;
laura.rosenberger@duke.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_10
89© The Author(s), under exclusive license to Springer Nature
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