Adrenalectomy

Principles

• Removal of all abnormal tissue (can sometimes do subtotal)
• Avoid gland handling - catecholamine surge, bleeding
• Warn the anaesthetist before clipping the vein

Choice of approach

• Laparoscopic theoretically has improved length of stay, pain, blood loss and complications
• Can be either trans-peritoneal or posterior retroperitoneal
• Favour laparoscopic retroperitoneal in:
  • Tumours <4cm (hard to get bigger tumours out of the body posteriorly)
  • Bilateral tumours
  • Likelihood of peritoneal adhesions
• Favour laparoscopic trans-peritoneal:
  • Likely to be more retroperitoneal fat - older, obese, male patients (makes entry and orientation difficult)
  • BMI >35
• Favour open: (prefer trans-abdominal approach through a subcostal incision)
  • Malignancy
    • Clinical feminisation
    • Hypersecretion of steroid hormones
  • Larger tumours
  • Suspected local or vascular invasion, regional lymphadenopathy, metastases

Laparoscopic transabdominal adrenalectomy

• IDC, SCDS
• 80-degree lateral decubitus with bed flexed to increase distance between ribs and iliac crest, using beanbag. Side of the lesion facing upwards. 10th rib directly over the break in the table. Try to leave the umbilicus exposed - important landmark.
• Prep from nipple line to pubis, from umbilicus to midline of back
• Left adrenal: (most important aspect is identification of correct plane of dissection)
  • Peritoneal access 2cm inferior to the costal margin in mid-clavicular line (generally optical). Ports equally distributed along the costal margin, with the lateral/posterior port as far laterally as permitted by the colon. Have 5cm between each port to minimise interference.
  • Take down the lateral attachments of the spleen and colon (phrenocolic, phrenosplenic) - rotate LUQ viscera medially off Gerota's. Then rightward tilt to the table, let the spleen, pancreas and stomach drop away, but leave kidney behind (similar to modified Mattox).
  • Identify upper pole of kidney, left renal vein, follow that to inferior phrenic vein entering superior part
  • Develop a plane just medial to adrenal gland and lateral to aorta. Open-book technique - left page is the spleen, tail of pancreas, and greater curvature. Right hand is kidney and adrenal tumour. Important structure - left inferior phrenic vein, identified using left crus of diaphragm. By developing this cleft of the open book, aim to find the adrenal vein at the inferomedial aspect of the adrenal gland, with the inferior phrenic vein leading you to it. Will come across some small adrenal arteries - use energy device.
  • Dissect out and clip or coagulate the left adrenal vein and divide
  • Dissect out the adrenal capsule, staying right on the capsule to avoid injury to superior pole renal artery branches
  • Take the specimen off the superior pole of the kidney and posterior abdominal wall - divide these attachments last because they are helpful in suspending the gland up until the last minute
  • Only need to close skin
• Right adrenal (most important aspect is avoidance of adrenal vein bleeding)
  • Mirror access to left side
  • Right triangular ligament of liver needs to be completely divided and liver rotated anteromedially
  • Left-hand page of open book is the kidney and adrenal gland, and right-hand page is the bare area of the liver
  • Open Gerota's and identify upper pole of kidney
  • Identify adrenal, IVC and adrenal vein
  • Develop space between adrenal gland and IVC by methodically moving from superior to inferior. Be mindful of adrenal vein variants - 10% have a significant second adrenal vein. Veins can be directly injured, lacerated from undue traction, or sheared by clips. Ligate it with two clips.
    • If loss of control of adrenal vein, will usually need to convert to open.

Laparoscopic retroperitoneal adrenalectomy

• Ligasure, endocatch
• Prone jack-knife with knees flexed and abdomen free to hang down away from the field
• Mark three ports 2cm inferior to the 12th rib. See diagram below for surface markings.
• Insert first (middle) port - 10mm. Initial pressure 20-28mmHg.
• Create working space into subcutaneous fat by bluntly dissecting retroperitoneal contents anteriorly, then inserting the other two ports.
• Divide uckerkandl's fascia
• Try to find the kidney by dissecting deep and towards midline, then delineate the superior pole
• Upper pole of kidney mobilised, and pushed inferiorly to expose the adrenal gland
  • In patients with more fat, may not be able to see the adrenal gland very clearly at all - in that case just resect everything en bloc between kidney, peritoneal reflection, then through to vein medially
• Mobilise adrenal gland, leaving a cuff of fat to avoid spilling it
  • Start near paraspinous muscles at inferomedial aspect - expect to usually encounter left adrenal vein here
  • On the right, the adrenal vein is found a bit later, as dissection proceeds superiorly
  • Look out for small arterial branches to be coagulated
  • Once the superior pole is reached, move circumferentially to include peri-adrenal fat
• Place in endocatch and remove
• Close skin

Open trans-abdominal

• Prep between nipples to pubis
• Supine, with ipsilateral side slightly elevated on a bolster
• Left
  • Subcostal incision
  • Either enter lesser sac through gastrocolic ligament and incise retroperitoneum inferior to tail of pancreas which will bring you to left renal and adrenal veins, or rotate the spleen medially and work in the same plane as laparoscopic trans-abdominal. Mostly the latter.
• Right
  • Complete mobilisation of right lobe of liver, including lateral attachments and falciform ligament, to allow medial rotation or caudal retraction of liver
  • Open Gerota's
  • Identify upper pole of kidney, then adrenal, IVC and adrenal vein
    • May need Kocher manoeuvre
  • IVC exposed by medial reflection of duodenum, peritoneum incised behind opening of lesser sac over IVC, and plane between IVC and adrenal gland developed
  • Adrenal vein ligated

Post-op

• Usually home day 1 for laparoscopic procedures or day 5-7 for open

Complications

• Bleeding
• SSI or deep infection
  • Seen especially with Cushing's
• Incisional hernia
• Subcostal nerve injury (retroperitoneal approach)
  • Usually transient abdo wall dysfunction
• Injury to surrounding organs
  • Pancreatic injuries and fistulas
• Post-op adrenal insufficiency
• Port site hernias/metastases
• Local recurrence
  • Associated with capsule rupture, especially in phaeochromocytoma