Page 38 - WJOLS - Laparoscopic Journal

Thawatchai Tullavardhana

But overall complication and length of hospital stay are not – Spleen: Splenic injury occurs during left adrenalectomy.
different. 15 This condition can be managed by argon plasma
coagulation and hemostasis agent. If this is not control
Natural Orifice Transluminal Endoscopic bleeding, splenorrhaphy or splenectomy may be
Surgery (NOTES) for Adrenalectomy necessary.

The concept of NOTES is “incisionless surgery”. This – Pancreas: If pancreatic injury occurs at tail of
technique access by transgastric or, transvagina or pancreas, distal pancreatectomy is a surgical option.
transcolonic approach to access peritoneal cavity. That can If there is uncertainty of pancreatic injury
allows perform intra-abdominal surgery without surgical management by leaving of closed suction drainage
scar. and total parenteral nutrition.
In present role of NOTES for adrenalectomy are only – Visceral organ: Small bowel, colonic injury may
reports in many porcine or cadaveric models. Transvaginal occur during laparoscopic adrenalectomy. If this
retroperitoneal adrenalectomy in porcine model is performing complication cannot repair by laparoscopic proce-
by made a 1 cm posterolateral colpotomy. The dure, conversion to open surgery may be an option.
retroperitoneal tunnel was created using carbon dioxide. Postoperative Complication
Dissection by movement of gastroscope up to superior pole
of kidney to allowed access of adrenal gland. The vascular 1. Hypokalemia can occur in the immediate period after
pedicle was identified and controlled by clips or endoloop. adrenalectomy in patient with primary hypoaldo-
NOTES transvaginal retroperitoneal may be option for steronism. Potasium replacement is requiring if this
humans in future. But further experiments and better condition still persistent replacement of mineralocorticoid
practice surgical skill are needed. 16,17 with fludrocortisone is essential.
2. Hypotension secondary to α blockade can occur after
Bilateral Adrenalectomy adrenalectomy in case of pheochromocytoma. Close
monitoring of blood pressure in postoperative period
The most common indication for bilateral adrenalectomy is still necessary.
Cushing’s syndrome. This procedure was performed by 3. Complication after prolong steroid supplement after
lateral transperitoneal approach. The larger tumor or the adrenalectomy such as increased risk of fracture
more difficult side should be performed first, then change secondary to osteoporosis, hyperglycemia, and poor
patient position to opposite side and redraped. 3,7 wound healing.
Mikhail et al report comparison of outcome between During learning period of laparoscopic adrenalectomy,
laparoscopic bilateral adrenalectomy with open surgery. The surgeon should select a case of unilateral, small adenomas
results of laparoscopic procedure are—(1) Need more without comorbid disease to avoid perioperative
operative time (295.2 vs 236.8 minutes) (2) Less complication. 19
intraoperative blood loss (100 vs 500 cc.) (3) Short hospital
stay in laparoscopic surgery group (3 vs 8.5 days). 18 Postoperative Care

Complication of Laparoscopic Adrenalectomy After completion of operation nasogastric was removed.
Carefully monitoring of blood pressure, fluid-electrolyte
Intraoperative complication
balance as mentioned in postoperative complication. Oral
1. Hemorrhage: Adrenal vein are directly into IVC on the intake can start on first operative day and take off urinary
right side and directly to left renal vein on the left. If catheter. Postopertive pain is control by parenteral narcotics
avulsion injury occur during dissection of adrenal vein in the first 24 hours. Then oral analgesic drug start after
may be cause of massive hemorrhage. Prevention of first operative day. If the patient was uneventfully, they
this complication by meticulous dissection of adrenal can discharge from hospital within 48 hours after surgery.
vein. Recovery time of patient is about 10 to 14 days after surgery.
2. Adjacent organ injury
– Liver: Liver laceration of liver retractor may be cause Benefit Outcome Compare with Open Surgery
of bleeding. This condition can be managed by argon In present, many of literature showing benefits outcome of
plasma coagulation and hemostasis agent (such as laparoscopic adrenalectomy above conventional open
methyl cellulose). surgery, include decrease blood loss during surgery,
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