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210
Fig. 23.6 Port placement
for retroperitoneoscopic
adrenalectomy
N. E. Kim and M. J. Livhits
Complications
– Bleeding can occur from venous hemorrhage or solid organ injuries. Bleeding
can be managed with direct pressure and increasing the insufation pressure
(maximum of 30mmHg for the retroperitoneoscopic approach). If there is a sig-
nicant IVC injury, the techniques above can be rst attempted to allow time for
denitive repair (placement of hemoclip or laparoscopic suturing), but early con-
version to open laparotomy should be considered.
– Damage to surrounding structures includes injury to hollow viscus structures,
such as thermal injury to the colon during a transabdominal approach. The pan-
creas can also be injured, creating stulas.
– During the dissection of a pheochromocytoma, care must be taken not to violate
the tumor capsule as tumor spillage can cause tumor recurrence. In addition,
intraoperative manipulation of a pheochromocytoma can cause hemodynamic
uctuations. Adequate pre-operative alpha blockade, excellent communication
with the anesthesiology team, avoiding direct pressure on the mass, and consid-
eration of early ligation of the adrenal vein are important to ensure hemodynamic
stability.
23 Minimally Invasive Adrenalectomy: Techniques andPotential Complications
211
– Infection and incisional hernia are potential complications, especially in patients
with immunosuppressive states such as those with Cushing’s syndrome. These
can include deep wound infection or intra-abdominal abscess.
– Hemothorax and/or pneumothorax are uncommon complications for either mini-
mally invasive approach.
– Complications unique to retroperitoneoscopic adrenalectomy include neuro-
pathic pain and abdominal wall relaxation, which are almost always temporary.
– Predictive factors for postoperative complications after minimally invasive adre-
nalectomy include tumor size, patient BMI, patient-associated comorbidities,
and previous surgeries.
References
1. Carr AA, Wang TS. Minimally invasive adrenalectomy. Surg Oncol Clin N Am.
2016;25(1):139–52. https://doi.org/10.1016/j.soc.2015.08.007. Epub 2015 Oct 31.
2. Conzo G, Tartaglia E, Gambardella C, Esposito D, Sciascia V, Mauriello C, Nunziata A,
Siciliano G, Izzo G, Cavallo F, Thomas G, Musella M, Santini L.Minimally invasive approach
for adrenal lesions: systematic review of laparoscopic versus retroperitoneoscopic adrenalectomy and assessment of risk factors for complications. Int J Surg. 2016;28(Suppl 1):S118–23.
https://doi.org/10.1016/j.ijsu.2015.12.042. Epub 2015 Dec 18.
3. Dickson PV, Jimenez C, Chisholm GB, Kennamer DL, Ng C, Grubbs EG, Evans DB, Lee
JE, Perrier ND. Posterior retroperitoneoscopic adrenalectomy: a contemporary American
experience. J Am Coll Surg. 2011;212(4):659–65. discussion 665-7. https://doi.org/10.1016/j.
jamcollsurg.2010.12.023.
4. Kwak J, Lee KE. Minimally invasive adrenal surgery. Endocrinol Metab (Seoul).
2020;35(4):774–83. https://doi.org/10.3803/EnM.2020.404. Epub 2020 Dec 23. PMID:
33397038; PMCID: PMC7803606.
5. Siperstein AE, Berber E, Engle KL, Duh QY, Clark OH.Laparoscopic posterior adrenalectomy: technical considerations. Arch Surg. 2000;135(8):967–71. https://doi.org/10.1001/
archsurg.135.8.967.
Chapter 24
Open Adrenalectomy: Techniques
andPotential Complications
AlaaSada andTravisJ.McKenzie
Introduction
Although minimally invasive adrenalectomy is currently considered the standard
approach for small and benign adrenal pathology, open adrenalectomy is still
required for selected cases. If primary adrenal malignancy is suspected (ex. adrenocortical carcinoma), an open approach is preferred in most circumstances as minimally invasive adrenalectomy is associated with higher rates of tumor rupture and
recurrence. Large adrenal tumors (>8cm) may also require open resection depending on the patient’s anatomy, the tumor pathology, and the surgeon’s experience.
Figure24.1 shows a large adrenocortical carcinoma that was resected through an
open approach.
Conversion from minimally invasive to open adrenalectomy is undertaken in
challenging situations when a minimally invasive approach cannot be safely performed. This may occur in situations of intra-operative hemorrhage or altered operative eld from previous intraperitoneal operations.
Anatomy
Given the location of the adrenal glands in the retroperitoneum adjacent to vital
vasculature including the aorta, inferior vena cava (IVC), and the renal hilar vessels,
the surgeon should review cross-sectional images including assessment for aberrant
anatomy. Open adrenalectomy is most commonly performed for large tumors or
when primary adrenal malignancy is suspected. Therefore, it is critical to assess if
A. Sada · T. J. McKenzie (*)
Department of Surgery, Mayo Clinic, Rochester, MN, USA
e-mail: Sada.Alaa@mayo.edu; Mckenzie.Travis@mayo.edu
Switzerland AG 2024
R. M. Gartland, J. A. Lee (eds.), Endocrine Surgery Clerkship, Contemporary
Surgical Clerkships, https://doi.org/10.1007/978-3-031-62091-1_24
213© The Author(s), under exclusive license to Springer Nature
214
Fig. 24.1 Large adrenal
tumor measuring 24cm
Fig. 24.2 Right adrenal
tumor on coronal CT scan
with IV contrast
A. Sada and T. J. McKenzie
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there is invasion into surrounding structures that may require multivisceral en bloc
resection. The surgeon must be prepared to resect involved organs, or portions
thereof, which may include the inferior vena cava, renal vasculature, kidney, distal
pancreas, spleen, portion of liver, stomach, colon, and/or diaphragm.
• Right Adrenal Gland
– The right adrenal gland is located cephalad to the right kidney and bounded
by the renal vessels inferiorly, IVC medially, and liver and diaphragm superiorly as shown in Fig.24.2.
– The right liver is mobilized completely to fully access and control the IVC
above and below the tumor.
– The right adrenal vein, which drains directly into the posterolateral IVC, is
short (approximately 1cm in length) and fragile. Bleeding due to injury to the
IVC in this area can be catastrophic.
• Left Adrenal Gland
24 Open Adrenalectomy: Techniques andPotential Complications
– The left adrenal gland is located cephalad to the left kidney and in close prox-
imity to the left renal vessels, posterior aspect of the pancreatic tail, spleen,
splenic vessels, colon and colonic mesentery, and fundus of the stomach, as
shown in Fig.24.3.
– The deep margin of the left adrenal gland is the psoas muscle and diaphragm
more superiorly.
Fig. 24.3 Left adrenal
tumor on coronal CT scan
with IV contrast
Aorta
Adrenal tumor
215
IVC
Le renal artery
216
A. Sada and T. J. McKenzie
Open Right Adrenalectomy Technique
• Open adrenalectomy can be performed through a midline, subcostal, or modied
Makuuchi (reverse L) incision. In our practice, we prefer a modied Makuuchi
incision when the tumor is large or multi-versal resection is anticipated as it provides wide exposure.
• For large adrenal tumors, full mobilization of the liver is performed thereby
allowing access to the IVC adjacent to the tumor.
• The right colon and hepatic exure are mobilized medially to access the retroperitoneum and the duodenum is fully Kocherized and reected to the left side.
• The right and left renal veins are identied, isolated, and controlled. The IVC
below and above the tumor are controlled. The surgeon must be aware of potential lumbar veins entering the IVC posteriorly. If found, these should also be
controlled or ligated and divided to prevent injury.
• Once the adrenal gland is identied, it is dissected free from surrounding structures, evaluating for signs of invasion. If the tumor is malignant and cannot be
separated from surrounding structures, en bloc resection may be performed.
• Dissecting the right adrenal gland off the IVC is a critical part in right adrenalectomy and is performed in order to identify the right adrenal vein which is divided
as it enters the IVC.Vascular isolation including proximal and distal control of
the IVC is advisable, particularly if tumor invasion into the IVC is suspected.
• Once the adrenal vein is divided, the remaining attachments of the adrenal glands
are taken along with ligation of the arterial supply until the gland is free.
• Throughout the dissection, care is taken to not directly violate the capsule of the
tumor as capsular injury can result in tumor seeding and early local recurrence.
Open Left Adrenalectomy Technique
• Once access to the peritoneal activity is achieved, the left colon and splenic exure are mobilized medially to access the left peritoneum as shown in Fig.24.4.
• The lateral attachment of the spleen can be dissected to retract the spleen medially as needed.
• The plane between the pancreas and Gerota’s facia is dissected using an “open
book technique” (Fig.24.5) while paying close attention not to injure the splenic
vessels. With the open book technique, the right lateral “page” of the book consists of the left kidney and adrenal gland while the left medial “page” consists of
the spleen, pancreas, and left colon. The book spine is the plane between the left
adrenal gland and the pancreas that needs to be dissected in order to identify the
left inferior phrenic and adrenal veins.
• Once the left adrenal vein is identied, it can be ligated and divided. The left
inferior phrenic vein can be either divided or preserved.
a b
24 Open Adrenalectomy: Techniques andPotential Complications
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217
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Fig. 24.4 Open left adrenalectomy: (a) Exposed left adrenal tumor. (b) Left adrenal tumor
resection bed
Fig. 24.5 Open book
technique illustration
• Finally, the left adrenal gland is dissected free from surrounding structures
including the retroperitoneal muscles along with ligation of the arterial supply
until the gland is free.
• As with right open adrenalectomy, supreme care should be taken to not violate
the tumor capsule. En bloc resection can be performed as needed to ensure complete resection.
218
A. Sada and T. J. McKenzie
Complications andOutcomes
• Compared to minimally invasive adrenalectomy, open adrenalectomy is associated with a longer operative time and hospital length of stay, longer recovery, and
higher rate of complications. The 30-day mortality rate of open adrenalectomy is
1.1% while the complication rate is 19%.
• Potential short-term complications following open adrenalectomy include but
are not limited to bleeding, surgical site infection, pneumonia, urinary tract
infection, venous thromboembolism, and injury to surrounding structures resulting in colonic, or pancreatic leak. These complications can be related to the magnitude of multi-visceral resection when performed, adrenal pathology and
associated hormonal abnormalities, and patient co-morbidities.
• With regard to adrenocortical carcinoma, long-term oncologic outcomes may be
improved with open adrenalectomy compared to minimally invasive adrenalectomy. Minimally invasive adrenalectomy may be utilized for very selected cases
of early stage, small adrenocortical carcinoma by expert surgeons facile with
minimally invasive surgery.
Part IV
Gastrointestinal Neuroendocrine
Chapter 25
Evaluation andDiagnosis ofPancreatic
andGastrointestinal Neuroendocrine
Tumors
DanielHubbs andThomasFahey III
Introduction
– Neuroendocrine tumors (NETs) can be found throughout the body and are
dened by their microscopic appearance and neuroendocrine differentiation.
– Gastroenteropancreatic NETs are a diverse group of tumors with marked vari-
ability in presentation and prognosis.
– Many NETs secrete functional peptides that can present as unique clinical
syndromes.
– Efcient initial evaluation and accurate diagnosis is key for management of func-
tional effects of the tumors and possible malignant consequences.
General [1–3]
Features
• NETs have histologic features consistent with normal neuroendocrine cells.
• Chromogranin A and Synaptophysin are neuroendocrine-specic markers that
can be seen on immunohistochemistry to help identify NETs.
• NETs are graded as G1 (low), G2 (intermediate), and G3 (high) based on histologic features such as mitotic rate, Ki-67 index, and degree of differentiation.
• NETs are generally divided into two groups: well-differentiated (WD-NET) and
poorly differentiated (PD-NET).
D. Hubbs (*) · T. Fahey III
Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital,
New York, NY, USA
e-mail: tjfahey@med.cornell.edu
Switzerland AG 2024
R. M. Gartland, J. A. Lee (eds.), Endocrine Surgery Clerkship, Contemporary
Surgical Clerkships, https://doi.org/10.1007/978-3-031-62091-1_25
221© The Author(s), under exclusive license to Springer Nature