Page 21 - World Journal of Laparoscopic Surgery

Malikendra Patel

been reported in selected patients, after resection of isolated instruments. During right adrenalectomies, a fourth 5 mm port
7
adrenal metastases. Since then, many series have confirmed was placed in a subxyphoid position for liver retraction.
that when metastasis is isolated to the adrenal gland, Occasionally during left adrenalectomies, a fourth port was
adrenalectomy by open or laparoscopic approach can achieve added below the tip of the left twelfth rib to provide blunt
long-term survival. 8 retraction of the kidney and/or adrenal gland. This technique
was particularly useful for larger tumors, which often
E. Others encroached upon the vascular hilum of the kidney, making
exposure of the adrenal vein difficult. Early ligation and division
Generally, myelolipoma and adrenal cyst are benign lesions of the adrenal vein was carried out prior to gland manipulation
that require no therapy. Larger, symptomatic or rapidly growing and dissection when possible.
tumors are treated with adrenalectomy, which is usually curative. For right adrenalectomies, the right hepatic lobe was
Infections, especially tuberculosis and histoplasmosis, can also completely mobilized to provide adequate visualization and safe
manifest themselves as an adrenal mass. Surgery may be access to the vena cava and adrenal vein. The triangular
indicated if medical treatment is ineffective. ligament was incised to the level of the diaphragm. The
retroperitoneum was then opened longitudinally along the
OBJECTIVE medial aspect of the adrenal gland, and immediately adjacent to
The aims of this study is evaluating the efficacy, safety and the lateral edge of the liver, until the vena cava was clearly
outcome of laparoscopic adrenalectomy for all adrenal benign identified.
and malignant tumors in comparison with open surgery, and Development of the plane between the inferior vena cava
also determine the risk factors which influence the outcome to and the medial margin of the gland was performed to expose the
identify those patients that are not good candidates for right adrenal vein. Early dissection and mobilization of the
laparoscopic approach. inferior retroperitoneal attachments to the tumor increased gland
mobility and made venous control considerably safer.
On the left, the splenic flexure was mobilized to allow access
MATERIAL AND METHODS
to the splenorenal ligament. The retroperitoneal plane superficial
A literature search was performed using search engine Google, to gerota fascia was developed to the level of the diaphragm,
High Wire Press, Springer Link and library facility available at allowing for medial rotation of the spleen and the pancreatic
laparoscopic hospital. Journal of clinical endocrinology and tail. A complete medial rotation of adjacent structures was critical
Metabolism. The Hongkong medical diary and ANZ journal of to provide adequate exposure of the adrenal gland and vein.
surgery. Gerota fascia was incised medial to the superior pole of the
kidney to provide access to the left adrenal vein and the adrenal
TREATMENT gland. The vein was then ligated and divided at its confluence
with the left renal vein.
Surgical treatment is the only option. Preoperatively in all On either side, the borders of the adrenal gland were first
patients with preoperative signs and symptoms of identified and then dissected away from the retroperitoneum,
catecholamine excess, alpha-adrenergic blockade was started using periadrenal fat as a “handle”. The larger glands, especially
10 days to 2 weeks before surgery. For patients with tachycardia, those greater than 5 cm, were most often resected with
beta-blockade was added. Patients with alpha blockade-induced periadrenal fat, exposing the psoas muscle from the renal hilum
orthostatic hypotension were treated with oral and/or cephalad to the diaphragm. The gland was never grasped to
intravenous volume loading during the 24 to 48 hours prior to avoid hemodynamic liability, troublesome bleeding, or tumor
surgery. Patients were infused with 1 to 2 L of crystalloid solution disruption. Large adrenal veins, typically those greater than 7
for intravascular volume expansion in the preoperative holding mm in width, were divided with an endovascular stapler.
area. It is wise to have all patients an arterial line and 2 large- Specimens were placed into an impervious extraction bag prior
bore peripheral intravenous lines or a central venous line placed to morcellation (if necessary) and removal. The peritoneum and
prior to the induction of general anesthesia. fascia at the trocar sites were closed endoscopically.
SURGICAL TECHNIQUE POSTOPERATIVE CARE

The adrenalectomies can be performed laparoscopically Crystalloid fluid challenge to treat postoperative hypotension.
through a lateral decubitus or supine transperitoneal approach, NG-tubes as indicated. Clear liquids can be given on the same
1,2
or lateral retroperitoneal approach. Briefly, a diagnostic night after surgery. Patients were discharged 3-5 days. Follow-
laparoscopy was performed at the beginning of each procedure up in OPD at 7 to 10 days and another at 3 to 4 weeks
to rule out local tumor invasion or diffuse metastatic spread. postoperatively, and subsequently as needed. Long-term
The lateral decubitus transperitoneal approach; which is the follow-up included frequent blood pressure monitoring for the
most popular; starts with three subcostal ports (5-12 mm) allowed first year, then yearly thereafter. Urinary metanephrine levels
for the introduction of a 30° laparoscope and 2 working are followed annually for a period of 5 years.

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