Laparoscopic left adrenalectomy

The description of the laparoscopic left adrenalectomy covers all aspects of the surgical procedure used for the management of benign disorders (Conn's syndrome, small hormone-secreting tumors, Cushing's syndrome, small virilizing adenoma, incidentaloma> 5 cm). Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, dissection, ligation of the veins, ligation of the arteries, end of dissection/extraction. Consequently, this operating technique is well standardized for the management of this condition.

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Laparoscopic   left   adrenalectomy

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Abstract
The description of the laparoscopic left adrenalectomy covers all aspects of the surgical procedure used for the management of benign disorders (Conn's syndrome, small hormone-secreting tumors, Cushing's syndrome, small virilizing adenoma, incidentaloma> 5 cm).
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, exposure, dissection, ligation of the veins, ligation of the arteries, end of dissection/extraction.
Consequently, this operating technique is well standardized for the management of this condition.
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2001-07
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WeBSurg.com, Jul 2001;1(07).
URL: http://www.websurg.com/doi-ot02en210.htm

Laparoscopic   left   adrenalectomy

1. Introduction
The first adrenalectomy via a transperitoneal approach was performed in 1889 and the first laparoscopy was performed in 1912. It was not until 1992, however, that Gagner et al. performed the first laparoscopic adrenalectomy.
Since then, this approach has become the gold standard for benign disorders, as it offers several advantages:
- a minimally-invasive approach to the procedure (which facilitates it);
- a magnified view of the operative field;
- improved control of the vascular pedicles, particularly in obese patients;
- minimal postoperative discomfort due to the absence of large surgical wounds;
- reduced wound morbidity;
- reduced hospital stay.

2. Anatomy
• Location
The left adrenal gland is an endocrine organ of variable shape, smaller than the right adrenal gland. This vital organ is located within the renal fossa, at the medial aspect of the upper pole of the left kidney. It is not attached to the kidney.
• Arterial vasculature
• Left superior pedicle
The left superior pedicle originates in most cases from the left inferior phrenic artery. It divides into short descending branches that enter the upper pole of the left adrenal gland.
• Left middle pedicle
The left middle pedicle is situated behind the accessory adrenal vein and originates directly from the aorta in most cases. It divides into short branches that enter the central part of the adrenal gland.
• Left inferior pedicle
The left inferior pedicle is located in an anterior inferior position relative to the left adrenal gland. It usually originates from the left renal artery and divides into short branches that enter the inferior part of the adrenal gland.
• Main adrenal vein
The left adrenal gland is essentially drained by the main adrenal vein, which joins with the left inferior phrenic veins to drain into the left renal vein.
• Phrenic vein
The left adrenal gland is essentially drained by the main adrenal vein, which joins with the left inferior phrenic veins to drain into the left renal vein.
3. Indications
Indications
- Small or non-secreting tumors are the best indication. These are:
- Conn’s tumor
- Cushing’s tumors
- Small virilizing and feminizing tumors should be approached cautiously. They are simple adenomas in most cases but the secretion can be the consequence of an adrenocortical cancer in about 30% of the cases.
- Incidentaloma with a size superior to 3 or 4cm (European and American references).

Relative indication
Bilateral tumors are a relative indication considering the overall operative time necessary to perform such a procedure.

Contraindications:

Patient-related:
- surgical history (major risks of adhesions making the transperitoneal approach impossible),
- surgical history of the kidney or liver (risky dissections). It is usually recommended to insert an optical trocar and to explore the adrenal region to make an optimal decision.

Adrenal gland related:
- large gland (from 8 to 10cm); The indication regarding the size of the gland is a quickly evolving data. When the limit was set to 8cm in 1995, the laparoscopic approach for tumors up to 14-15cm is accepted. In these large tumors, the dissection can be started by a laparoscopic approach that should be converted into an open approach in case of difficulties, difficult landmarks identification or risk of capsular rupture of the gland.

- problem of carcinoma: The problem of laparoscopic resection for malignant tumors remains controversial. In fact, limited data exists in the literature (Kebebew E et al., Arch Surg, 2002). However, the most recent references consider that laparoscopic approach in patients with suspected adrenal metastases can be achieved by a laparoscopic approach. In the same way, laparoscopic adrenalectomy for adrenal cancer is not systematically a contraindication.
However, it is well demonstrated that laparoscopic adrenalectomy for clinically unsuspected adrenocortical cancer is associated with a high recurrence rate probably due to the aggressivity of this lesion, but perhaps also accidental rupture of the capsula of the gland in hazardous dissection.

- intracranial hypertension and coagulation disorders are common contraindications in laparoscopic procedures.
- age, obesity, and compromised cardiac or respiratory function are no longer considered contraindications. Furthermore, these high-risk patients may benefit more than others from parietal wall and musculature preservation in the postoperative course.
4. Preoperative management
The workup and localization of benign adrenal tumors depends on the suspected underlying pathology. Standard workup consists of a detailed clinical history and physical examination complemented by appropriate laboratory and radiologic evaluation (CT, MRI, scintigraphy).

Since the work of Meurisse et al. (1995) and Fernandez-Cruz et al. (1996), pheochromocytoma of the adrenal gland is no longer considered a contraindication to laparoscopic resection. However, appropriate preparation using alpha followed by beta-receptor blockade, or alternatively by calcium channel blockers, is highly recommended.
5. Operating room set-up
• Patient
The patient is placed in right lateral decubitus, flexed at the waist.
A cushion is placed under the contralateral lumbar fossa, which opens the operative field, thereby facilitating trocar placement.
• Team
1. The surgeon stands on the abdominal side of the patient.
2 + 3. Two assistants stand on the other side of the patient.
Two video monitors are used.
• Equipment
1. Operating table
2. Anesthetic equipment
3. Laparoscopic unit
4. Monitors
5. Electrocautery/ultrasonic scalpel
6. Instrument table
For optimal safety conditions, the operating room should be ergonomic, allowing ample space for the laparoscopic and anesthetic equipment.
6. Trocar placement
• Optical device
The 0° optical trocar is introduced in the left subcostal position.
• Operating devices
The second 10 mm trocar (used only for operating purposes) is introduced on the anterior axillary line behind the optical trocar.
• Retractors
Two 10 mm trocars are introduced on either side of the first trocar and placed under the costal margin. They will be used alternately for retracting or operating instruments.
7. Instrumentation
• Pneumoperitoneum
A 12 to 15 mm Hg pneumoperitoneum is established following standard principles.
Four trocars are usually required.
The position of the trocars may vary with the patient's body habitus.
• Optical devices
A 0° laparoscope is commonly used.
A 30° laparoscope may be necessary, especially:
- in obese patients,
- in case of large tumors.
• Operating devices
We routinely perform the dissection with a hook.
However, all of the instruments illustrated may be used.
• Retractors
A second 10 mm trocar is placed inferior to the left costal margin, 10 cm from the xiphoid process. It is used to introduce a 5 mm grasper.
8. Major principles
A left adrenalectomy is more difficult than a right adrenalectomy, because of the absence of major anatomic landmarks like the IVC, the smaller size of the left main adrenal gland and vein, and the presence of retroperitoneal fat as well as the tail of the pancreas in the operative field.

Our operative strategy is based on complete isolation of the adrenal gland without clearly identifying it beforehand.

The key to the procedure’s success is to begin with dissection of the lienophrenic ligament using a dissecting hook. This dissection is carried out cephalad till one can visualize the greater curvature of the stomach and the left crus.

This allows for the entire mobilization of the spleen, which falls away from the operative field to the right, along with the pancreatic tail. It is no longer necessary to exert any medial traction on the spleen.
The left splenic flexure is not dissected, even if it is necessary to free a few parietal adhesions for the introduction of the external trocar.
9. Exploration
• Exploration of the cavity
Video-assisted surgery permits complete exploration of the abdominal cavity.
• Associated pathologies
Perisplenic or colonic adhesions, which could result in a painstaking dissection, can be identified during exploration.
10. Exposure
• Mobilization of the spleen
To facilitate access to the vessels of the adrenal gland, the spleen must be reflected from the operative field.
This is achieved by dividing the lienophrenicligament.
The lateral decubitus position is used to expose the lienophrenic ligament.
• Division of the splenorenal ligament
Dissection is started from the inferior pole of the spleen and is extended up to the left crus of the diaphragm.
The posterior surface of the spleen is dissected first, followed by that of the pancreas. The medial reflection of the spleen and pancreas exposes the renal vein and the main adrenal vein.
• Captions
1. Lienorenal ligament
• Use of laparoscopic ultrasonography
In our early experience (before our current operative strategy based on vascular landmarks had been completely defined), one patient was converted to an open procedure because the adrenal gland could not be identified in the perirenal fatty tissue. Miccoli et al. have also come across this difficulty, which they resolved by the use of laparoscopic ultrasonography. We recommend this approach.
11. Dissection
• Splenic vein
Dissection of the splenic vein and pancreatic tail for at least 5 cm progressively exposes the renal vein, followed by the adrenal vein.
Dissection of the splenic vein is pursued for at least 5 or 7 cm on the posterior surface of the pancreas.
• Renal vein
Dissection of the splenic vein exposes the renal vein, which must be clearly identified.
It is then dissected on its superior aspect until the main adrenal vein is exposed.
• Adrenal vein
The main adrenal vein is dissected cephalad for 2 cm.
This reveals its convergence with an inferior phrenic vein.
• Pitfalls and complications
In the common pitfalls related to the laparoscopic approach (bowel and vascular injuries, gas embolism, operative difficulties linked to adhesions, obesity, etc.), specific side-related problems can be observed.

These are for a left adrenalectomy:
- splenic injury;
- pancreatic injury;
- vascular anatomy confusion, especially between the main adrenal vein and the renal vein;
- division of a polar renal artery;
- rupture of the capsula of the gland;
- injury of the diaphragm.

Complications linked to the pathology of the gland will not be specifically detailed as they are not related to the laparoscopic approach; e.g., hypertension during surgery for pheochromocytoma, carcinosis linked to surgery for adrenocortical carcinoma.
12. Ligation of the veins
• Main adrenal vein
The main adrenal vein (1), which has already been dissected, is clipped at the level of the renal vein and divided.
• Inferior phrenic vein
The inferior phrenic vein (1) is then dissected using a hook, clipped, and divided.
• Captions
1. Main adrenal vein
2. Accessory adrenal vein
13. Ligation of the arteries
• Middle adrenal artery
The middle adrenal artery (1), which originates from the aorta, is located posterior to the accessory adrenal vein.
Once identified, it is dissected from the aorta in the fatty tissue, clipped, and divided.
• Superior adrenal artery
The gland is gently retracted outwards using a peanut swab, to facilitate access to the superior adrenal artery (1) located on the right superior medial surface of the gland.
The superior adrenal artery, which originates from an inferior phrenic artery, is identified at the upper part of the gland. It is dissected, clipped, and divided. At this point, the upper part of the gland is entirely freed from the diaphragm.
• Inferior adrenal artery
The superior and posterior aspects of the gland, and then its left external aspect, are dissected free from their fatty tissues.
Cephalad retraction of the gland using a peanut swab is again necessary at this point of the procedure. This facilitates the search for the inferior adrenal pedicle (1).
This pedicle originates from the renal artery. It is located on the inferior posterior surface of the gland and is often composed of 2 or 3 vascular rami. These are individually dissected using a hook, then clipped and divided.
• Vascular rami
In some patients, the inferior pedicle is composed of rami that must be dissected in order to complete the arterial dissection.
At this point in the procedure, the gland is totally freed from the kidney.
14. End dissection/extraction
• End of the dissection
The vascular network of the gland has now been almost completely divided. The goal is to free the gland completely and proceed to its extraction.
The few attachments located between the inferior lateral aspect of the gland and the upper part of the kidney are carefully dissected using either a monopolar or bipolar coagulating hook.
• Extraction
The gland, now completely freed, is introduced into the extraction bag.
The extraction itself is performed through a trocar opening, which can be slightly enlarged depending on the individual case.
• Control and closure
At the end of the procedure, a close suction drain may be placed for 24 to 48 hours. Nowadays, we no longer recommend this placement of suction drain systematically.
All port sides over 5 mm are closed by intra-fascial sutures and subcutaneous sutures close the port incisions.
15. Postoperative management
- the patient may ambulate on the same day.
- liquid intake resumes the night of the procedure.
- normal diet resumes on the first postoperative day.
- the patient may leave the hospital on POD2 or POD3.
16. Reference
Berber E, Tellioglu G, Harvey A, Mitchell J, Milas M, Siperstein A.Comparison of laparoscopic transabdominal lateral versus posterior retroperitoneal adrenalectomy. Surgery 2009;146:621-5; discussion 625-6.

Boylu U, Oommen M, Lee BR, Thomas R. Laparoscopic adrenalectomy for large adrenal masses: pushing the envelope. J Endourol 2009;23:971-5.

Castillo OA, Vitagliano G, Secin FP, Kerkebe M, Arellano L. Laparoscopic adrenalectomy for adrenal masses: does size matter? Urology 2008;71:1138-41.

Dimas S, Roukounakis N, Kafetzis I, Bethanis S, Anthi S, Michas S, Kyriakou V, Kostas H. Feasibility of laparoscopic adrenalectomy for large pheochromocytomas. JSLS 2007;11:30-3.

Duh QY, Siperstein AE, Clark OH, Schecter WP, Horn JK, Harrison MR, Hunt TK, Way LW. Laparoscopic adrenalectomy. Comparison of the lateral and posterior approaches. Arch Surg 1996;131:870-5; discussion 875-6.

Eto M, Hamaguchi M, Harano M, Yokomizo A, Tatsugami K, Naito S. Laparoscopic adrenalectomy for malignant tumors. Int J Urol 2008;15:295-8.

Heniford BT, Arca MJ, Walsh RM, Gill IS. Laparoscopic adrenalectomy for cancer. Semin Surg Oncol 1999;16:293-306.

Hobart MG, Gill IS, Schweizer D, Sung GT, Bravo EL. Laparoscopic adrenalectomy for large-volume (> or = 5 cm) adrenal masses. J Endourol 2000;14:149-54.

Kebebew E, Siperstein AE, Clark OH, Duh QY. Results of laparoscopic adrenalectomy for suspected and unsuspected malignant adrenal neoplasms. Arch Surg 2002;137:948-51; discussion 952-3.

Kercher KW, Novitsky YW, Park A, Matthews BD, Litwin DE, Heniford BT. Laparoscopic curative resection of pheochromocytomas. Ann Surg 2005;241:919-26; discussion 926-8. Surg Oncol 2003;12:105-23.

Lal G, Duh QY. Laparoscopic adrenalectomy--indications and technique.

Linos DA, Stylopoulos N, Boukis M, Souvatzoglou A, Raptis S, Papadimitriou J. Anterior, posterior, or laparoscopic approach for the management of adrenal diseases? Am J Surg 1997;173:120-5.

Moinzadeh A, Gill IS. Laparoscopic radical adrenalectomy for malignancy in 31 patients. J Urol 2005;173:519-25.

Parnaby CN, Chong PS, Chisholm L, Farrow J, Connell JM, O'Dwyer PJ. The role of laparoscopic adrenalectomy for adrenal tumours of 6 cm or greater. Surg Endosc 2008;22:617-21.

Toniato A, Boschin IM, Opocher G, Guolo A, Pelizzo M, Mantero F. Is the laparoscopic adrenalectomy for pheochromocytoma the best treatment? Surgery 2007;141:723-7.