Page 27 - World Journal of Laparoscopic Surgery

Our Experience with Laparoscopic Adrenalectomy
Right Adrenalectomy of the patients had intraoperative fluctuations of blood pressure
(Fig. 1) Four ports were used normally. Three ports of 10 mm (1 for which was managed successfully by an anesthetist. These patients
30 degree scope and 2 as working ports) each were placed along eventually had pheochromocytomas on histology. The patient
the right costal margin and one 5 mm port at the xiphisternum for who was pregnant had intraoperative accelerated hypertension
liver retraction. An additional 5 mm fifth port would be inserted for with a maximum recording of 230/110 mm Hg, managed by inj.
liver retraction if required, in the right anterior axillary line. nitroprusside and nitroglycerine (NTG) drip.
The triangular ligament was first cut and the peritoneum was Five out of 37 patients had to be converted to the open
incised along with the liver as far as the diaphragm so that the right technique. One of them had multiple adhesions with the bowel
lobe of the liver falls away medially. The plane was created between because of past abdominal surgery for duodenal perforation which
liver and adrenal and dissection proceeded medially reaching the made the separation of bowel difficult. One patient had retrocaval
adrenal vein. tumor extensions and was densely adherent to IVC and liver with
After complete dissection of the vein, it was cut between clips. a size of 8.5 × 7 cm. It eventually turned out to be adrenocortical
The gland was then dissected free using a hook with monopolar carcinoma. Two patients were converted to open because of the
coagulating current and delivered after placement in endobag. difficulty in dissection and prolonged operative time due to large
The specimen was extracted via a 10 mm port, by enlarging the tumor size. One of the patients had severe hepatomegaly. Despite
incision. The port sites were closed using the standard technique. adding a fifth retraction port, separation of tumor from the liver
bed was difficult, so the decision was taken to proceed with open
Left Adrenalectomy surgery. The characteristics of patients converted to open along
Port placement on the left side was similar to the right. Four ports with reasons for the same have been summed up in Table 2.
were used.
The peritoneum was incised along the White Line of Toldt in a dIscussIon
“T” shaped manner. Studies have suggested that large tumors are not a contraindication
The two horizontal limbs of T extended from colon caudally for LA, but some authors do not approve laparoscopic approach for
to splenocolic ligament in the cephalad direction till the greater large tumors because of increased risk of malignancy, especially in
curvature of the stomach was visible. tumors with infiltration to surrounding structures on computerized
This allowed complete retraction of the spleen and the colon tomography (CT), which may even lead to peritoneal dissemination
by positional gravity and exposed the kidney enveloped in the
Gerota’s fascia. The vertical limb of “T” was the line of dissection
between the tumor and spleen. Dissection was done at the site of Table 1: Patients’ characteristics
the renal hilum, for identification of the adrenal vein, which was Total patients 37
clipped and divided. The adrenal gland was then dissected free Mean age in years (range) 46 (27–65)
from the surrounding structures and delivered in a retrieval bag. Sex Male—15 (40.54%)
Females—22 (59.45%)
results Average BMI in kg/m (range)
2
The demographic details and patient characteristics have been Side Right—16 (43.24%)
summed up in Table 1. Out of 37 patients, 32 were evaluated Left—20 (54.05%)
and found to have functional tumors. Eventually, 31 of them had B/L—1 (2.7%)
pheochromocytoma on histopathology and 1 patient had adrenal Any significant history 1 female—5 months pregnant
hyperplasia leading to Cushing’s syndrome. One patient had sudden 1 male—past history of abdominal
cardiovascular collapse at the time of induction but was resuscitated surgery for duodenal perforation
on time and the patient went on with the surgery successfully. Most Mean size in cm (range) 6.05 cm (2.5–9.6 cm)
Functional tumors 32 (31 pheochromocytomas and 1
patient of Cushing’s disease)
Final histopathology Nonfunctioning adenomas—4
Pheochromocytoma—31
Adrenocortical carcinoma—1
Adrenal hyperplasia—1

Table 2: Reasons for conversion to open adrenalectomy
No. of patients converted to open Reason for conversion
1 Hepatomegaly in a right-sided
tumor
1 Adherent to kidney, liver, and
retrocaval extension—eventu-
ally malignant
2 Large tumor size
1 Past abdominal surgery leads to
Fig. 1: Port placement for right adrenalectomy adhesions with bowel

126 World Journal of Laparoscopic Surgery, Volume 13 Issue 3 (September–December 2020)