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ENDOCRINE SURGERY
Table 33.1. Indications for adrenalectomy
Functional Tumors
Pheochromocytoma
Conn’s syndrome (aldosteronoma)
Cushing’s syndrome
Cortosol-secreting adenoma
Bilateral adrenal hyperplasia
Ectopic adrenocorticotropic hormone (ACTH) syndrome
Pituitary-dependent Cushing’s disease unsuccessfully managed
by transsphenoidal surgery
Virilizing/feminizing tumors
Adrenocortical carcinoma
Nonfunctional Tumors
Incidental adrenal mass (incidentaloma) >3–4 cm
or increasing in size
Isolated metastasis from another site
Symptomatic cyst or angiomyolipoma
Adrenocortical carcinoma
patients are also hypokalemic, and preparation
for surgery includes replenishing total body
potassium stores using potassium, spironolactone, a competitive aldosterone antagonist in
the distal tubules of the kidney, or both [3].
flank, and posterior (retroperitoneal) approaches,
with the thoracoabdominal approach usually
reserved for large and/or invasive tumors.
Laparoscopic approaches similarly include the
transperitoneal or retroperitoneal approach.
The decision as to whether to perform an
open or laparoscopic adrenalectomy depends
on many factors, including preoperative suspicion for malignancy, presence of local invasion
into surrounding structures, tumor size, and
surgeon experience. Since the first laparoscopic
adrenalectomy was done in 1992 by Gagner and
colleagues [6], it has become the preferred
approach in most circumstances. Multiple studies have demonstrated the advantages of the
laparoscopic approach, including less operative
blood loss, fewer postoperative complications,
decreased requirement for parenteral analgesics, faster resumption of regular diet, decreased
length of hospital stay, and faster return to regular activities [7–11].
Because most adrenalectomies today are performed via the laparoscopic approach, its technique will be discussed first. Open adrenalectomy is
sometimes necessary for large or invasive tumors,
and details specific to an open dissection will then
be discussed.
Cushing’s Syndrome
Preparation for surgery in a patient with Cushing’s syndrome requires treatment of the metabolic effects of excess cortisol secretion. This
includes management of hypertension, excellent
blood glucose control, and correction of electrolyte disturbances. In the case of patients who
require bilateral adrenalectomyfor the treatment
of their disease [e.g., those with ectopic adrenocorticotropic hormone (ACTH) syndrome, those
with bilateral adrenal hyperplasia, or those with
pituitary-dependent disease unsuccessfullymanaged by transsphenoidal surgery], preoperative
ketoconazole, a cytochrome p450 inhibitor that
inhibits various steps of steroid biosynthesis, is
giventodecreasecortisolsecretion[4,5].
Operative Approach
Adrenalectomy can be performed via an open or
laparoscopic approach. The most common open
techniques include the anterior (transabdominal),
Anatomic and Technical
Considerations
The adrenal glands are paired structures located
in the retroperitoneum, superior to the kidneys.
The differences in surrounding structures
between the right and the left adrenal glands are
well-known, and details regarding exposure and
dissection will be given in the following sections.
One of the most vital anatomic details to
remember is the difference in blood supply
between the right and the left sides. While the
arterial blood supply is similar on both sides,
the venous drainage is very different. The arterial blood supply consists of the superior adrenal
artery (from the inferior phrenic artery), the
middle adrenal artery (from the aorta), and the
inferior adrenal artery (from the renal artery).
These arteries are frequently not discrete vessels
and their branches are usually easily controlled
with electrocautery.
The venous drainage consists of one dominant vein that must be ligated or clipped, with
441
TECHNIQUE OF OPEN AND LAPAROSCOPIC ADRENALECTOMY
smaller accessory veins that follow the arteries
andcanusuallybecontrolledwithelectrocautery. Of note, in patients with larger tumors,
very vascular tumors, or obviously malignant
tumors, these accessory veins can become very
large and may require ligation or clips as well.
The right adrenal vein is very short, and drains
into the posterolateral aspect of the inferior
vena cava (IVC), while the left adrenal vein is
longer, and drains into the left renal vein. Of
note, the left inferior phrenic vein is usually
seen medial to the left adrenal vein, and it joins
the left adrenal vein before its junction with the
left renal vein. Identification and control of the
adrenal veins is one of the most important (and
sometimes one of the most challenging) parts
of adrenalectomy.
Intraoperative Considerations
As adrenalectomy is done under general
anesthesia, all patients should receive perioperative deep vein thrombosis (DVT) prophylaxis. Only those with Cushing’s syndrome
require preoperative antibiotics, which should
be effective against gram-positive organisms.
Patients with Cushing’s syndrome should also
receive preoperative stress-dose glucocorticoids
[12]. A Foley catheter should be placed.
In addition to the standard monitors and
equipment, some patients require special
additional considerations. Despite adequate
alpha –beta blockade, patients with pheochromocytomas can have wide swings in their
blood pressure during surgery, and thus
should have an arterial line and central venous
catheter placed, with medications readily
available to control hypo- or hypertension.
Patients with obviously invasive and malignant tumors, in whom en bloc resection of
adjacent organs is planned, should similarly
have an arterial line and central venous catheter. In addition, for patients in whom IVC
invasion and/or tumor thrombus is seen or
suspected, vascular instruments and preparation for venovenous bypass may be necessary.
As with the planning of any operation, anticipation of potential complications and preoperative preparation for those will ensure
that the operation proceeds as safely and as
smoothly as possible.
Technique of Laparoscopic
Adrenalectomy
Laparoscopic adrenalectomy may be performed
via a transabdominal (transperitoneal) or posterior (retroperitoneal) approach, with the
transperitoneal approach performed more commonly. Advantages of the transperitoneal
approach include more familiar anatomy
and the ability to do a general abdominal
exploration. Advantages of the retroperitoneal
approach include direct access to the adrenal
gland with decreased need for intraabdominal
dissection. Major limitations of this approach,
however, are the difficulty in converting to an
open procedure in the case of a vascular injury,
and that the small working space only allows
resection of tumors measuring 5–6 cm or smaller. Multiple studies have demonstrated the
safety and efficacy of both techniques, with
both retrospective and prospective randomized
studies showing no difference between the two
techniques with respect to operative time, blood
loss, postoperative analgesic requirement,
length of stay, or time to return to normal activities [13–16]. In addition, a cost analysis model
similarly showed no difference between the
techniques [17]. Thus, which technique to
choose depends on surgeon preference, which
may be influenced by tumor size, presence of
bilateral tumors, or history of previous abdominal surgery.
Laparoscopic Transabdominal
(Transperitoneal)
Adrenalectomy
Patient, Equipment, and Surgeon
Position
Laparoscopic transperitoneal adrenalectomy
can either be done with the patient in the supine
(referred to as the anterior approach) or in the
lateral decubitus position (referred to as the
lateral approach). The anterior approach has
the advantage of being able to do a bilateral
adrenalectomy without having to reposition
the patient; however exposure of the adrenal
gland is more difficult using this approach.
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ENDOCRINE SURGERY
Fig. 33.1. Patient position for laparoscopic transperitoneal right adrenalectomy via the lateral approach. The patient is placed in
the right lateral decubitus position on a gel-covered beanbag, with the break in the table located at or just cephalad to the costal
margin.
The lateral approach has the advantage of being
able to use gravity to retract the liver on the
right, and the spleen and tail of pancreas on
the left. Because of this significant advantage
and because the lateral approach is more commonly used, this approach will be described,
with our modifications of the original technique
reported by Gagner and colleagues [6, 7, 18].
The patient is positioned on the operating
room table in the lateral decubitus position
(with side of the adrenal pathology facing up)
on a gel-covered beanbag, with the break in the
table located at or just cephalad to the costal
margin (Fig. 33.1). The arm closest to the table is
extended on an armrest, with the other arm
supported with pillows or on another elevated
armrest. An axillary roll is placed. The leg closest to the table is flexed, the other leg straight,
and pillows placed between them. All pressure
points should be well-padded.
The table is then flexed, the kidney rest
raised, the patient positioned at about 808 (108
posterior lean), and suction applied to the beanbag. Take care to not allow the beanbag to be too
close to the anterior abdominal wall, as this may
limit excursion of the abdomen during insufflation. The patient should be taped to the table in
three places: over the lower extremities, over the
hip, and over the chest. The table should then be
tilted in multiple directions to make sure that
the patient doesnot move. Taking the extra time
required for proper positioning is essential for
the smooth performance of the operation.
The patient is prepared and draped from
beyond the umbilicus to the spine, and from
below the iliac crest to the nipple. Video monitors are placed at the patient’s head, and the
surgeon and assistant stand on the side facing
the patient’s abdomen.
Equipment
A list of recommended equipment is given in
Table 33.2. Laparoscopic adrenalectomy is per-
formed using three or four trocars, which may be
10–12 or 5 mm in size, depending on the size of
the camera, fan retractor, dissecting instruments,
clip-applier, and other preferred equipment,
such as an ultrasonic shear or electrothermal
bipolar tissue-sealing device. A 308 angled
laparoscope is essential. A fan retractor is useful
Table 33.2. Recommended instruments for laparoscopic
adrenalectomy
One or two video monitors
Three or four 10–12 or 5 mm trocars
308 angled laparoscope (10 or 5 mm)
Two blunt, atraumatic bowel graspers
Fan retractor
Hook cautery
Suction and irrigation device
Medium-large clip-applier
Ultrasonic shear or electrothermal bipolar tissue sealing device
Tightly rolled X-ray detectable gauze sponges (cigarette
sponges)
Impermeable nylon bag
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TECHNIQUE OF OPEN AND LAPAROSCOPIC ADRENALECTOMY
to retract the liver during right adrenalectomy,
and sometimes helpful to retract the spleen during left adrenalectomy. X-ray detectable gauze
sponges tightly rolled-up like a cigarette are
very helpful for blotting and retracting, but can
only beplaced through a 10-mm or larger port. A
laparoscopic ultrasound probe (5–7.5 MHz) is
helpful in select cases, such as in an obese patient
in whom a small adrenal tumor is lost in the
retroperitoneal fat, or when the adrenal venous
anatomy is unclear [19]. A thick impermeable
nylon bag is used to remove the specimen from
the patient.
Right Adrenalectomy
Four trocars are placed about 2 cm below the
right costal margin as shown (Fig. 33.2). The
medial-most trocar, placed first at the lateral
border of the rectus muscle, should be a
10-mm port through which the fan retractor
will be placed. The abdomen is insufflated to
Fig. 33.2. Trocar position for laparoscopic transperitoneal
right adrenalectomy.
15 mm Hg, and the abdomen is visually
explored. The lateral-most trocar is placed
next at the costovertebral angle under direct
vision. The remaining two trocars are placed
such that the spacing between the four ports is
equal and maximal. The camera is inserted
through the second port, hook cautery through
the third port, and an atraumatic bowel grasper
through the lateral-most port.
The first step involves mobilizing the liver
and opening the space between the liver and the
retroperitoneum just like opening the pages of a
book. The fan retractor is used to retract the
liver medially. The lateral attachments of the
liver and right triangular ligament are then
taken down using the hook cautery, allowing
the liver to rotate medially, and exposing the
right adrenal tumor and IVC. The dissection
extends cephalad all the way up to the diaphragm, taking care to avoid injuring the diaphragm and causing a pneumothorax. This is
most prone to happening in patients with Cushing’s syndrome due to the friability of their
tissues. It is very rare to need to mobilize the
hepatic flexure of the colon in order to get
further exposure.
The next step involves mobilization of the
adrenal gland itself. This dissection is initially
done in a top-down manner: the superomedial
aspect of the gland and its surrounding periadrenal fat is dissected away from the liver, proceeding in a cephalad to caudad manner, until
the muscles of the retroperitoneum are seen. It
is helpful to hold a tightly rolled X-ray detectable gauze sponge in the grasper of the left hand
to provide lateral traction. The small vessels off
the inferior phrenic artery and vein identified
during this part of the dissection can generally
be cauterized. This initial dissection creates a
‘‘V’’ shaped opening ‘‘unzipping’’ the superomedial aspect of the adrenal gland from the liver, so
the dissection can proceed from cephalad to
caudad toward the adrenal vein.
As the dissection moves to the inferomedial
aspect of the gland and the liver is mobilized and
retracted away from the adrenal gland, the lateral
aspect of the IVC is identified and gently dissected away from themedial aspect of theadrenal
gland. The right adrenal vein will be encountered
and should be carefully dissected circumferentially, then clipped with at least two clips on the
IVC side before being transected. Be aware that
once its main venous drainage is interrupted, the
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ENDOCRINE SURGERY
adrenal gland can become engorged and the dissection can become more bloody, particularly for
tumors such as pheochromocytomas. Meticulous
attention to hemostasis is essential.
Once the adrenal vein is taken, the next step is
to dissect thegland away from the renal hilum. At
this stage of the dissection, we usually use a blunt
grasperto lift the adrenal cephalad from the renal
hilum by insinuating it between the inferolateral
aspect of the adrenal and the kidney near the
upper edge of the hilum. Retracting the adrenal
gland away from the renal hilum facilitates the
dissection ofthe inferior adrenal artery branches,
and most importantly helps identify and avoid
injuring a possible superior pole branch of the
renal artery. A small superior pole renal artery
branch can easily be mistaken for the inferior
adrenal artery, and injuryto thisartery can result
in renal vascular hypertension.
Once the adrenal gland is safely dissected
away from the renal hilum, the remainder of
the dissection involves separating the adrenal
tumor from the upper pole of the kidney, and
then dividing its superolateral and posterior
attachments. This part is done last, as these
attachments greatly aid in holding the adrenal
gland in place during all of the previous dissection. Here, again we use a grasper placed
between the kidney and the adrenal to hold the
adrenal gland up, and we use either an ultrasonic shear or electrothermal bipolar tissue sealing device to complete the dissection. The
surface of the upper pole of the kidney is usually
seen at the completion of this dissection.
The specimen including adrenal tumor and
surrounding periadrenal fat should then be
placed in an impermeable nylon bag and
removed from the patient. This can be done
either by breaking up the tumor and removing
it piecemeal through the 10- to 12-mm port, or
by extending the skin and fascial incision of one
of the port sites. The dissection bed should then
be inspected to assure hemostasis, the ports
withdrawn under direct vision, and the fascia
and skin closed in the standard fashion.
get good medial retraction of the spleen and tail
of pancreas using gravity. We prefer four ports
because it is often helpful to use an atraumatic
grasper or fan retractor to retract the spleen and
tail of pancreas medially.
The first step in this dissection involves mobilizing the spleen and tail of pancreas and, similar
to right adrenalectomy, opening the space
between the spleen and the retroperitoneum just
like opening the pages of a book. Exposure begins
by mobilizing the splenic flexure of the colon
inferiorly using the hook cautery and retracting
it inferiorly away from the kidney. The splenorenal ligament is then incised along the lateral
border of the spleen, and the dissection proceeds
cephalad to the diaphragmatic attachments and
short gastric vessels. It is not necessary to divide
the short gastric vessels. The spleen and tail of
pancreas can then be easily retracted medially. It
is important not to dissect too far laterally and
enter the plane posterior to the kidney.
The next step of the dissection is very similar to
that of right adrenalectomy, in that mobilization of
the left adrenal gland begins with a top-down dissection at the superomedial aspect of the gland and
proceeds in a cephalad to caudad manner until the
muscles of the retroperitoneum are seen. The dissection should continue caudad along the medial
aspect of the glanduntil the left adrenal vein is seen.
The left inferior phrenic vein is usually seen first
parallel and medial to the medial edge of the adrenal. Once the anatomy of the inferior phrenic vein
and the adrenal vein is clearly delineated, the inferior phrenic vein can be clipped and transected. This
helps mobilize the adrenal gland superolaterally
and makes dissection and ligation of the adrenal
vein easier and safer.
After dividing the adrenal vein, the remainder of the operation is identical to that of right
adrenalectomy. Again, lifting the adrenal gland
away from the renal hilum is important to avoid
injuring a possible superior pole renal artery.
Laparoscopic Posterior
Left Adrenalectomy
Trocar size and position is identical to that of
right adrenalectomy, although the left side can
be done with three ports (if desired, omit the
medial-most port) rather than four if one can
(Retroperitoneal)
Adrenalectomy
The technique of retroperitoneal adrenalectomy
was first described by Mercan and colleagues in
1995 [20]. Since that time, several authors have
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TECHNIQUE OF OPEN AND LAPAROSCOPIC ADRENALECTOMY
reported on their series and modifications of the
original technique [21, 22].
Patient, Equipment, and Surgeon
Position
The patient is positioned on the operating room
table in the prone jackknife position, with the
back level and the chest and abdomen supported
laterally by parallel bolsters, thus allowing for
abdominal excursion during insufflation. Video
monitors are placed at the patient’s head, and the
surgeon and the assistant stand at the foot of
the bed.
Equipment
In addition to the equipment listed in Table 33.2,
additional equipment helpful to perform laparoscopic retroperitoneal adrenalectomy includes
transcutaneous ultrasound (with a 3.5- to 5-MHz
transducer) and laparoscopic ultrasound (with a
5- to 7.5-MHz transducer), as well as a 10-cm
spherical dissecting balloon.
Adrenalectomy
Fig. 33.3. Trocar position for laparoscopic retroperitoneal
right adrenalectomy.
Three trocars are placed below the tips of the
twelfth and eleventh ribs as shown (Fig. 33.3).
Their exact position is guided by identifying the
locations of the ribs, kidney, and adrenal tumor
by ultrasound. Prior to preparing and draping
the patient, the outline of the twelfth rib is
drawn on the patient, as well as the outline of
the kidney and adrenal tumor as identified by
transcutaneous ultrasound. The initial 12-mm
trocar is placed 2 cm inferior and parallel to the
twelfth rib, at about the level of the lower pole of
the kidney. A 08 laparoscope is then inserted.
The first step is to create a space within
Gerota’s fascia posterior and superior to the
kidney by blunt dissection with the tip of the
08 laparoscope. The trocar is then aimed and
advanced to the level of the superior pole of the
kidney. The trocar is then withdrawn and
replaced with a 10-cm spherical dissecting balloon. The balloon is used to further develop the
space. The balloon is then withdrawn, the trocar
replaced, and the retroperitoneum insufflated to
20 mm Hg of pressure. This amount of pressure
in the retroperitoneum is usually well-tolerated,
and greatly aids in maintaining hemostasis
during the dissection [22]. The two additional
trocars (either 10–12 mm or 5 mm) are placed
under direct vision on either side of the first
trocar. A 308 laparoscope is then inserted into
the medial-most port (closest to the spine) and
used for the remainder of the procedure.
The next step involves identification and dissection of the adrenal gland. Laparoscopic ultrasound may be useful to identify the location and
extent of the adrenal tumor. The dissection is
then done using hook cautery, an ultrasonic
shear or electrothermal bipolar tissue sealing
device, or bluntly with atraumatic bowel graspers. The dissection commences at the inferior
aspect of the gland, separating it from the upper
pole of the kidney, which is then retracted caudally. The dissection then continues along the
medial aspect of the gland and proceeds in a
cephalad direction. The adrenal vein is encountered and controlled with clips similar to the
transperitoneal approach. The superolateral
attachments are taken last, as they help hold
the adrenal gland in place during the inferior
and medial dissection.
446
ENDOCRINE SURGERY
Extraction of the tumor and surrounding
periadrenal fat, and closure of the fascia and
skin incisions are similar to that done in the
transperitoneal approach.
Technique of Open
Adrenalectomy
As stated above, laparoscopic adrenalectomy has
become the gold standard for extirpation of adrenal tumors. However, an open approach is necessary in some circumstances, such as when a
tumor is large or there is invasion into neighboring structures. Many have recommended that
tumors larger than 6–8 cm in diameter should
be approached open, but larger tumors have
been resected laparoscopically as long as there
are no obvious signs to suggest malignancy [23].
Open adrenalectomy may be done via an anterior
(transabdominal), thoracoabdominal, flank, or
posterior (retroperitoneal) approach. An epidural
catheter is helpful for postoperative pain control.
Anterior (Transabdominal)
and Thoracoabdominal
Approaches
Patient and Surgeon Position
Patient positioning is similar for the transabdominal and thoracoabdominal approaches. For the
transabdominal approach, the patient is placed
supine on the operating table with the arms
tucked or extended on armboards at the sides.
In addition, for the thoracoabdominal approach,
the patient should be placed on a beanbag with a
shoulder roll placed vertically under the flank of
the side of the adrenal tumor. This helps elevate
the chest on that side, and allows access to the
lateral-most extent of the incision. The arm on the
side of the adrenal tumor should be tucked. Surgeon position depends on surgeon preference.
Equipment
approach requires equipment necessary to clear
and transect a segment of rib, along with a rib
spreader for exposure. A double-lumen endotrachial tube is helpful. A vascular set and preparation
for venovenous bypass may be necessary. A chest
tube and pleurovac are necessary at the end of the
case.
Incision
The choice of incision for open transabdominal
adrenalectomy dependson tumoranatomy, including size and invasiveness into surrounding structures. Various incisions include vertical midline,
extended subcostal [subcostal incision extending
superiorly over the xiphoid (sometimes requires
cutting the xiphoid with a pair of heavy scissors;
can also be extended to afull median sternotomy as
an alternative to the thoracoabdominal approach)],
bilateral subcostal, and thoracoabdominal.
While the thoracoabdominal incision provides excellent exposure, it may cause more morbidity associated with the opening of two body
cavities, more pain, and the potential for other
complications such as phrenic nerve injury during division of the diaphragm [24]. The thoracoabdominal incision is planned out over the
eighth or ninth rib, extending from the posterior
axillary line along the rib and curving over the
abdominalwalltowardtheumbilicus.The
abdominal part of this incision should be made
first, and the peritoneal cavity explored for metastatic disease. If none is found, then the thoracic
part of the incision can be continued. The latissimus dorsi, serratus anterior, and intercostal muscles are divided. The cartilaginous costal arch is
transected. The pleura is entered along the superior aspect of the rib (remember that the neurovascular bundle runs just inferior to the rib). A
periosteal elevator is used to clear the rib, and an
approximately 4-cm segment of rib is removed to
allow for exposure. The diaphragm is divided in a
circumferential fashion along its periphery. It is
helpful to place marking sutures every 2–3 cm on
either side of the divided diaphragm in order to
help align it during closure. A rib spreader can
then be inserted to provide exposure.
Standard equipment and retractors are used toperform open adrenalectomy. As the adrenal tumor is
located in the retroperitoneum, a headlight is
very helpful. In addition, the thoracoabdominal
Right Adrenalectomy
Similar to laparoscopic right adrenalectomy, the
first step involves mobilizing the liver medially
447
TECHNIQUE OF OPEN AND LAPAROSCOPIC ADRENALECTOMY
and superiorly by taking down the lateral
attachments and right triangular ligament. In
contrast to laparoscopic adrenalectomy, further
exposure of the adrenal gland is obtained by
reflecting the hepatic flexure of the colon inferiorly, and performing a Kocher maneuver of the
duodenum to expose the IVC. If there is concern
about invasion into adjacent organs, en bloc
resection of the kidney or part of the liver may
be necessary. If there is concern for invasion of
or tumor thrombus in the IVC, vascular control
of the supra- and infra-hepatic IVC should be
obtained before commencing dissection of the
tumor. Note that in addition to the adrenal vein,
large and/or invasive tumors may have multiple
large parasitic blood vessels that also need to be
ligated. Figure 33.4 shows an example of a 13.5cm right adrenocortical carcinoma that
required en bloc nephrectomy for resection.
Left Adrenalectomy
There are two approaches to the left adrenal
gland. Similar to the laparoscopic approach,
the left adrenal tumor may be exposed by
reflecting the splenic flexure of the colon inferiorly, and mobilizing the spleen and tail of pancreas medially. A second approach involves
entering the lesser sac by dividing the gastrocolic ligament in its avascular plane. The peritoneum inferior to the pancreas is then incised,
followed by incising Gerota’s fascia, and then
reflecting these structures superiorly. This
infra-pancreatic approach dissects a smaller
space and is suitable mainly for smaller and
more inferiorly positioned tumors. Sometimes
both dissections are necessary in order to obtain
good exposure. Again, if there is concern about
invasion into adjacent organs, en bloc resection
may be necessary.
Closure
Each surgeon has his/her own preferred method
for closure. A variety of types and sizes of suture
may be used. A subcostal incision should be
closed in two layers (anterior and posterior rectus sheath). If a thoracoabdominal incision was
used, a chest tube should be placed and the
diaphragm reapproximated using a running or
Fig. 33.4. Computed tomography scan of a patient with a 13.5-cm right adrenocortical carcinoma whose resection also required
en bloc nephrectomy via a thoracoabdominal approach.
448
ENDOCRINE SURGERY
interrupted monofilament suture. The previously placed marking sutures help align the
two sides. In order to take tension off the diaphragmatic closure, the costal cartilage should
be reapproximated using either a heavy monofilament suture or a stainless steel wire before
completion of the diaphragmatic closure. The
ribs should then be approximated with interrupted heavy monofilament or Tevdek sutures,
followed by closure of the serratus anterior and
latissimus dorsi muscles in two layers.
Flank and Posterior
(Retroperitoneal) Approach
The flank and open posterior retroperitoneal
approaches are not commonly performed, as
large and/or invasive tumors should be resected
via a transabdominal or thoracoabdominal
approach, and smaller tumors that would be
amenable to these approaches should be
resected laparoscopically. Thus, these techniques will not be discussed.
Postoperative Care
The postoperative care of apatient who has undergone adrenalectomy depends on the operative
approach, extent of resection, and functional or
nonfunctional nature of the tumor. For patients
who have undergone laparoscopic or open adrenalectomy without en bloc resection of adjacent
organs, the postoperative care is routine, consisting of pain control, continuation of DVT prophylaxis, and early ambulation. A nasogastric tube is
unnecessary and can be removed in the recovery
room. Patients who have undergone laparoscopic
adrenalectomy may have a general diet as tolerated immediately. Those who have undergone
open adrenalectomy may have a postoperative
ileus, and may take a day or two before they are
ready for a general diet. Patients with functional
tumors require special considerations.
Pheochromocytoma
Because patients with pheochromocytomas can
have hemodynamic instability postoperatively,
they should be monitored in the postanesthesia
or intensive care unit for a minimum of 4 h
before being transferred to a regular ward.
Alpha blockade should be discontinued. If beta
blockade was given preoperatively, it should be
continued and weaned postoperatively. Studies
examining the role of perioperative beta blockade in patients undergoing noncardiac surgery
(not specific to pheochromocytomas) vary in
the duration of postoperative therapy from
2–30 days after surgery [25, 26].
Aldosteronoma
Similar to patients with pheochromocytoma, all
antihypertensive medications except beta
blockers should be discontinued in patients
who have undergone adrenalectomy for aldosteronoma. Spironolactone should be discontinued, and the patient’s serum potassium checked
the morning after surgery. Blood pressure
should be checked as an outpatient, with reinstitution of one or more additional antihypertensive medications if necessary.
Cushing’s Syndrome
Patients with Cushing’s syndrome should
receive prophylactic antibiotics and stressdose glucocorticoids perioperatively [12].
Because the function of the contralateral adrenal gland will be suppressed, these glucocorticoids will need to be continued postoperatively,
to be tapered over the next several months.
Mineralocorticoid replacement is only necessary if the patient has undergone bilateral adrenalectomy. Blood glucose control usually
improves after the operation.
Summary
In summary, laparoscopic adrenalectomy has
become the gold standard approach for patients
requiring this operation, and may be done via a
transperitoneal or retroperitoneal approach.
Large and/or invasive tumors that may require
en bloc resection are approached via the open
transabdominal or thoracoabdominal approach.
The postoperative care of these patients depends
on operative approach, extent of resection, and
functional nature of the tumor.
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TECHNIQUE OF OPEN AND LAPAROSCOPIC ADRENALECTOMY
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