Page 22 - World Journal of Laparoscopic Surgery

Open versus Laparoscopic Adrenalectomy for Multiple Adrenal Disorders

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COMPLICATIONS fold; epinephrine, 17.4-fold). Rocha et al also reported that
such hormonal release occurs despite an early adrenal vein
The advent of laparoscopy for advanced surgical procedures ligation, likely due to the extensive vascularity of
has given rise to specific risks of intraoperative complications. pheochromocytomas. Careful adrenal dissection, using
Complications being reported in the literature included tissue periadrenal fat as a handle, with minimization of direct
injury (liver, spleen, pancreas, kidney, duodenum and colon), manipulation or compression of the gland itself, is critical to
vascular injury (hepatic artery, splenic artery, venal cava and avoid catecholamine release. Intra-abdominal insufflation during
adrenal veins), and major hemorrhage. Postoperative laparoscopic pheochromocytoma excision may alone cause an
complications such as hematoma, infection and port-site increase in serum catecholamines. 6-10
herniation have also been reported. The overall complication This stimulus may be via either a direct tumor compression
rates reported in various literatures, including the local one, or a change in tumor perfusion. The pneumoperitoneum with
were around 4%, and the mortality was less than 1%. 2,11-13 The CO may lead to hypercapnia and acidosis, which, in turn, are
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conversion rate was around 4-5% for various approaches of known stimuli of catecholamine secretion and hypertension. 6-
laparoscopic adrenalectomy. In most cases, the reason for 11 Rocha et al found a more than 10-fold elevation in
conversion was bleeding, difficult dissection, or intraoperatively catecholamines during abdominal insufflation to 12 mm Hg with
suspected malignancy.
CO , with about 50% of patients experiencing hypertensive
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episodes. As a result, helium has been suggested as an
OUTCOME AND ANALYSIS alternate insufflation agent to eliminate the deleterious effects
Compared with those who underwent a standard open approach, of CO during laparoscopic adrenalectomies for adrenal tumors.
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patients undergoing a laparoscopic adrenalectomy have In a prospective evaluation of 11 patients undergoing helium
demonstrated decreased perioperative morbidity, shorter insufflation during laparoscopic pheochromocytoma resection,
hospitalization, and faster functional recovery. 3-4 the authors demonstrated that its use avoided significant
intraoperative hypercarbia or acidosis and provided greater
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intraoperative hemodynamic stability. Interestingly, though,
DISCUSSION
there were no differences between the CO and the helium
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Surgical treatment offers the cure for all adrenal tumors (benign insufflation groups in either serum catecholamine surges or
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or malignant). Despite the improvements in perioperative medical overall surgical outcomes. When compared with other
management, anesthesia, and surgical techniques, adrena- indications for adrenalectomy, laparoscopic resection of adrenal
lectomy for adrenal tumors carries morbidity rates as high as tumors, results in longer operative times, higher complication
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40% and perioperative mortality rates of 2 to 4%. Fears of rates, and longer hospitalization. With growing experience using
cardiovascular instability due of excessive catecholamine release advanced laparoscopic techniques, conversion rates have
caused by the pneumoperitoneum and/or laparoscopic decreased from 22 to 0-4%. 12-14 The “learning curve” may play
dissection have urged concerns over the role of laparoscopy in a significant role in improving the efficiency and safety of
adrenalectomy. Continuous invasive monitoring and advanced laparoscopic procedures. Extreme care must be
pharmacologic intervention by an experienced anesthesia team exercised to avoid intraoperative capsular disruptions and
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are necessary to avoid substantial cardiovascular instability. possible iatrogenic pheochromocytomatosis. Li et al reported
The surgeon must avoid excessive tumor manipulation, which 3 cases of pheochromocytoma recurrence 3 to 4 years after
can result in catecholamine release. Tumor manipulation has initial laparoscopic resection and possible tumor spillage. As a
been shown to be the most important intraoperative factor for result, many investigators have suggested that laparoscopy be
catecholamine release during both open and laparoscopic avoided for pheochromocytomas larger that 7 to 8 cm. 12-17
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adrenal resections. Fernandez-Cruz et al demonstrated that Conversion to an open procedure is warranted, however, when
mean plasma norepinephrine and epinephrine increased 13.7 laparoscopic dissection cannot be performed safely or a
and 34.2-fold during open tumor manipulation. complete resection cannot be performed without undue trauma
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Thompson and associates performed a matched case- to the gland.
control study comparing 50 patients having open adrenalectomy It has been agreed by several authors that a posterior
to 56 patients having adrenalectomy through a posterior retroperitoneal LA is preferable to an anterior LA, especially
approach. They found that LA, compared to OA, was inpatients who have either bilateral adrenal tumors, prior
significantly associated with shorter hospital stay, less toextensive abdominal procedures with resultant adhesions and
postoperative narcotic use, more rapid return to normal activity, scar tissue formation, or pre-existing cardiopulmonary
increased patient satisfaction, and less late morbidity. However, disease. 18,19 Posterior LA is not indicated in patients with large
the laparoscopic procedure was associated, with longer adrenal tumors. The absolute contraindications for laparoscopic
operating room time and higher cost. Similar results have been adrenalectomy include primary or metastatic invasive adrenal
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reported by Prinz and by Brunt et al, who found that LA had malignancies because extensive en bloc surgery and node
distinct advantages compared to OA. Laparoscopic tumor dissection will be necessary. As well as coagulopathy, which
manipulation was associated with a significantly diminished can’t be controlled preoperatively. Size of the tumor correlates
increase in plasma catecholamine levels (norepinephrine, 8.6- with malignant potential. Weight greater than 100 gm or size
World Journal of Laparoscopic Surgery, September-December 2009;2(3):19-22 21