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12 Surgical Treatment ofPrimary Aldosteronism
175
Transperitoneal (Transabdominal) Adrenalectomy
The laparoscopic transperitoneal adrenalectomy is most commonly performed via a
lateral approach [27] though some surgeons perform an anterior approach, especially in cases of other types of adrenal pathology where bilateral adrenalectomy is
indicated [28, 29]. One advantage of the lateral position is that gravity allows the
viscera to retract away from the surgical eld. We prefer the lateral approach.
We prefer to use a beanbag for positioning which is placed on the operating table
during room preparation. Draw sheets both below and on top of the beanbag facilitate positioning. The patient is initially placed supine on the operating table and
general anesthesia is induced. Secure intravenous access should be assured. In most
cases, continuous blood pressure monitoring via arterial access and central venous
access is not needed, though may be necessary in some patients due to specic
comorbidities. A Foley catheter should be placed. Sequential compression devices
are applied. The patient is moved if necessary, so that the space superior to the iliac
crest lies over the break point of the table. The patient is then turned into the full
lateral position with the appropriate side up. The table is exed fully to open the
space between the costal margin and iliac crest. The beanbag is then deated. The
arms are positioned in neutral positions away from the operative eld. The legs are
padded and secured in a neutral position.
Transabdominal Approach totheRight Adrenal Gland
The abdomen is entered either via a closed technique and the Veress needle or open
technique according to surgeon’s preference, and pneumoperitoneum is established
to 15mmHg. The rst port is usually positioned just medial to the anterior axillary
line. On the right side, usually a total of four ports are required as one will be needed
for liver retraction. The right lobe of the liver is retracted cephalad for exposure to
the retroperitoneum. Dissection is begun with opening of the posterior peritoneum
just inferior to the liver (Fig.12.1). In thinner patients, the inferior vena cava (IVC)
is usually visible just beneath the peritoneum. In larger patients, some dissection
may be required before the IVC becomes apparent. Dissection continues along the
border of the inferior vena cava to identify the right adrenal vein (Fig.12.2). The
right adrenal vein is a short, sizable vein often located cephalad to the inferior to the
edge of the liver. Early identication, dissection, and division of the right adrenal
vein are important to avoid surgical complication. The right adrenal vein is clipped
and then divided. The adrenal gland can then be dissected away from the IVC
(Fig.12.3). Dissection is carried along the adrenal gland with cautery or an energy
device, separating the gland from the retroperitoneal and perirenal adipose tissue.
During dissection, it is important not to directly grasp the adrenal gland. This will
cause the capsule to rupture resulting in copious bleeding that is difcult to control.
Disruption of the tumor may cause seeding of the surrounding space and diffuse
176
Fig. 12.1 Early view
during transabdominal
right adrenalectomy. The
arrow points to the adrenal
gland. The liver is retracted
cephalad. Dotted lines
indicate the inferior
vena cava
Fig. 12.2 Transabdominal
right adrenalectomy. The
short adrenal vein has been
exposed (arrow)
L. Kim and J. C. Mira
regrowth of tumor. Usually, the adrenal arterial supply is well controlled with cautery alone, but occasionally, larger vessels may require a clip or an energy device.
The superior pole of the kidney will become visible and the pararenal fat is taken
along with the adrenal. Care should be taken when dividing the pararenal fat because
the irregular shape of the adrenal gland may cause the surgeon to inadvertently
leave behind an adrenal limb. Once separated from the retroperitoneum, the adrenal
gland is placed in a laparoscopic collection bag and removed. We prefer a strong
bag that can tolerate substantial pressure since inadvertent spill of adrenal contents
during extraction can be disastrous. The extraction site is closed at the level of the
fascia to decrease the risk of incisional hernia. No drains are necessary.
12 Surgical Treatment ofPrimary Aldosteronism
Fig. 12.3 Transabdominal
right adrenalectomy. The
adrenal gland is being
mobilized away from the
inferior vena cava. The
white arrow points to the
edge of the adrenal gland.
The black arrow points to
the clipped stump of the
adrenal vein
Fig. 12.4 Transabdominal
left adrenalectomy. The
spleen and pancreas
complex have been
mobilized anteriorly to
expose the left adrenal
gland (dotted ellipse)
177
Transabdominal Approach totheLeft Adrenal Gland
The patient is placed in the left lateral decubitus position and the abdomen is entered
as described above. Usually, a total of three ports are adequate on the left (a camera
port and two working ports). The splenic exure of the colon is mobilized if necessary to expose the retroperitoneum. Gravity assists on medial retraction of the
splenic exure. The splenorenal and splenophrenic ligaments are divided, and the
peritoneum at the inferior edge of the pancreas is incised to allow for medialization
of the spleen and tail of the pancreas. Care is taken to avoid inadvertent pancreatic
injury. It is critical that the kidney is left undisturbed and the spleen/pancreas complex is mobilized as a unit. This will be an avascular plane that opens with gentle
traction and blunt dissection. Gravity will aid in the anterior retraction of the spleen.
The left adrenal gland may be visible in thin patients (Fig.12.4). Gerota’s fascia is
178
L. Kim and J. C. Mira
opened to expose the adrenal gland. Dissection is carried on the inferior border of
the adrenal gland to identify the left adrenal vein as it drains into the left renal vein.
The left adrenal vein is then identied, clipped, and divided (Fig.12.5). The inferior
phrenic vein may sometimes be seen as it joins the adrenal vein and may be preserved or transected, as necessary. Dissection is carried along the inferior border of
the left adrenal gland. Renal vessels will be nearby, and appropriate caution should
be taken to avoid their injury. Dissection is carried along the adrenal gland with
cautery separating the gland from the retroperitoneal and perirenal adipose tissue.
The superior pole of the kidney will become visible (Fig.12.6). The adrenal gland
is placed in a laparoscopic collection bag and the incisions closed as described above.
Fig. 12.5 Transabdominal
left adrenalectomy. The
adrenal vein has been
clipped but not yet divided.
The left renal vein is
outlined by the dotted lines
Fig. 12.6 Transabdominal
left adrenalectomy. The
adrenal gland has been
almost completely
dissected free. The kidney
(long arrow) and renal
artery branches (short
arrows) are seen
12 Surgical Treatment ofPrimary Aldosteronism
179
Retroperitoneal Adrenalectomy
Retroperitoneoscopic adrenalectomy was rst described in 1995 by MK Walz [30].
This approach may be favored in patients with prior abdominal surgeries and is
feasible in the obese [31]. Patients may be positioned in the lateral or prone genuect position. A large series by Walz of over 500 retroperitoneoscopic adrenalectomies showed excellent outcomes with zero mortality and 1.3% risk of major
complications [32]. Several groups have compared laparoscopic transabdominal
versus retroperitoneal adrenalectomies [33–35]. While some have favored retroperitoneal adrenalectomies for decreased operative times, blood loss, and hospital
length of stay, others have found no signicant difference, particularly in terms of
complication rates [33–35]. The Society of American Gastrointestinal and
Endoscopic Surgeons recommends that surgeons need to perform the approach they
are more familiar with and provide the best outcomes in their practice [36].
The patient is placed in the prone genuect position with all pressure points
padded. A 1.5–2cm incision is made at the tip of the 12th rib, and dissection is
carried bluntly to the retroperitoneal space. The initial working space is opened
with blunt dissection with the surgeon’s nger. Lateral and medial to this incision
are two laparoscopic working trocars placed using nger guidance. A sealing balloon or another trocar is placed in the initial incision, and the retroperitoneum is
insufated to 20mmHg to create a working space. The space is further developed
using blunt dissection over the superior pole of the right kidney retracting the
kidney caudally and laterally. The inferior aspect of the adrenal gland is identied and completely dissected off the superior pole of the kidney and retracted
cephalad (Fig.12.7). If operating on the right side, the adrenal vein is identied
at its insertion to the IVC medially and ventrally. If operating on the left side, the
renal vein may be identied and the adrenal vein is recognized as it enters the
Fig. 12.7 Posterior
retroperitoneal left
adrenalectomy. Early view
of the left adrenal gland
(arrow)
180
Fig. 12.8 Posterior
retroperitoneal left
adrenalectomy. The
grasper holds the adrenal
vein. A left inferior phrenic
vein can be seen joining
the left adrenal vein
(arrow)
L. Kim and J. C. Mira
renal vein. On the left, the inferior phrenic vein is often seen as it enters the adrenal vein (Fig.12.8). The adrenal vein is dissected circumferentially, clipped, and
divided. The adrenal gland is dissected off its retroperitoneal attachments superiorly and laterally using cautery or an energy device. The gland is removed in a
collection bag.
Robotic Adrenalectomy
Robotic surgery has become increasingly common in elective procedures.
Adrenalectomy is often performed with robotic assistance, either via the transabdominal or retroperitoneal approach. There is still debate on the benets of robotic
surgery over laparoscopy in adrenal surgery. Overall, there appears to be no difference in overall complications, with some studies favoring decreased blood loss and
length of stay for robotic surgery while increasing costs [37, 38]. We prefer to use
the robot for the transperitoneal approach because of improved visualization, dexterity, and ability to handle difcult situations such as a vascular injury. However,
we agree that the cost is higher and improved patient outcomes have not been clearly
shown. We do not use a non-robotic accessory port because of the limited working
space, though many surgeons do use an accessory port. With the posterior approach,
the available space between ports is very limited. For that reason, the use of a robot
may be difcult or impossible. Certainly, older robotic systems are particularly
problematic because of bulk. Newer, single-port systems might prove especially
useful for the posterior retroperitoneal approach. For now, we prefer not to use the
robot for the posterior approach (Fig.12.9).
12 Surgical Treatment ofPrimary Aldosteronism
Fig. 12.9 Typical
aldosteronoma showing the
classic golden-yellow color
of a cortical adenoma. The
specimen has been inked
181
Partial Adrenalectomy
An adrenal sparing approach has been suggested in patients with unilateral APAs
detected on imaging studies. Proponents of this approach note decreased risk of
adrenal insufciency with comparable cure rates and no increase in complications
[39, 40]. However, results are mixed. Other groups have shown increased rates of
persistent aldosteronism after partial adrenalectomy [41–43]. These groups demonstrate two ndings: (1) sectioned specimens show hyperplastic nodules at resection
margin adjacent to targeted adenoma and (2) nodules detected on imaging studies
are not always APAs, even with ipsilateral AVS lateralization, likely secondary to
the former. While data has shown improvement in subclinical transient hypocortisolism with partial adrenalectomy when compared to total adrenalectomy (11.5%
vs 25%, p< 0.001), rates of clinically signicant adrenal insufciency requiring
supplementation are equivalent (2.6% vs 1.9%, p=0.489), with no patients developing persistent hypocortisolism in either group [39]. Present guidelines recommend against partial adrenalectomy in PA given the risk of persistent
hyperaldosteronism without signicant benet over total adrenalectomy [3].
Complications
Laparoscopic adrenalectomy is a safe procedure with a 30-day mortality of <1%
and morbidity of 6.8–14.4% [32, 44, 45]. A granular data with regard to the complication grade and specic type of complications are generally lacking. Surgical morbidity after laparoscopic adrenalectomy can be classied in common complication
categories as in other types of abdominal procedures: bleeding, injury to adjacent
182
L. Kim and J. C. Mira
structures, conversion to open (for minimally invasive approaches), thromboembolic events, infections, cardiac events, pulmonary complications, complications
related to anesthesia and positioning, and nerve injuries, among others. Medical
complications related to adrenalectomy specic to primary aldosteronism may also
be observed: clinically signicant hyperkalemia and adrenal insufciency requiring
medical treatment.
Bleeding complications occur <4% in laparoscopic adrenalectomy [46, 47].
Careful dissection along the IVC and left renal veins must be undertaken with careful liver and splenic retraction to minimize events of major hemorrhage from vascular or parenchymal injury. In fact, while rates of conversion from laparoscopy to
laparotomy are <5%, open conversion is most associated with bleeding, less commonly due to extensive adhesive disease, visceral injury, and suspicion of malignancy [45, 47, 48]. Others have noted higher rates of bleeding in the right-sided
procedures while injury to adjacent organs was higher on the left side [47]. Failure
to respect the short right adrenal vein and careless dissection along the IVC on the
right or the inferior pancreatic border on the left can account for major bleeding
complication. Rates of pulmonary complications, postoperative infections, thromboembolic events, and cardiac events approach 1% or less each [44]. Drains are not
placed at the time of adrenalectomy but may be warranted in the event that a pancreatic injury is suspected as this facilitates a control of the pancreatic stula.
Following adrenalectomy, hyperkalemia has been observed in up to 6.3% of
patients secondary to contralateral suppression of aldosterone secretion with about
one third of these patients requiring mineralocorticoid replacement therapy [49].
Adrenal insufciency requiring steroid supplementation may occur in up to 2.6% of
patients [39].
Postoperative Care
Following adrenalectomy, electrolytes should be monitored to observe for development of hyperkalemia [3]. To minimize undesired hyperkalemia, potassium supplements and mineralocorticoid receptor antagonists should be stopped, balanced
crystalloid solutions without added potassium should be used for intravenous uid
therapy, and a low-potassium and high-sodium diet is recommended [50]. If hyperkalemia does not resolve spontaneously, mineralocorticoid replacement is necessary and continued outpatient monitoring is warranted [50]. Serum aldosterone
concentration and renin activity should be measured after surgery to ensure normalization of the aldosterone/renin ratio as evidence of biochemical response [3].
Finally, antihypertensives should be held and stopped if appropriate, keeping in
mind that it may require up to 3 months for hypertension to resolve after surgery
[51]. Patients should be reassessed annually with measurement of blood pressure
and serum potassium levels [10].
12 Surgical Treatment ofPrimary Aldosteronism
183
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