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26 ADRENALECTOMY
Abdelrahman A. Nimeri, M.D., and L. Michael Brunt, M.D., F.A.C.S.
The surgical approach to the adrenals has evolved substantially comprises two discrete anatomic and functional units: the adren-
over the past decade with the development and refinement of al cortex, which is the site for synthesis and secretion of cortisol,
techniques for performing laparoscopic adrenalectomy. At pres- aldosterone, and adrenal androgens; and the medulla, which is
ent, the majority of adrenal tumors are removed laparoscopically derived from the neural crest and is the site for synthesis of the
because minimally invasive approaches result in reduced pain, catecholamines epinephrine and norepinephrine. A normal
faster recovery, and fewer complications and because the rate of adrenal gland typically weighs between 4 and 6 g and measures
adrenal malignancy is low. Nevertheless, open adrenalectomy still approximately 4 to 5 cm by 2 to 3 cm by 0.5 to 1 cm. The right
has a role in the management of selected patients with large or adrenal is relatively pyramidal in shape, whereas the left is some-
malignant tumors. With both open adrenalectomy and laparo- what flattened and is more closely applied to the kidney. Grossly,
scopic adrenalectomy, several different surgical approaches to the the adrenals may be distinguished from the surrounding retroperi-
adrenals are possible [see Operative Planning, Choice of Proce- toneal fat by their golden-orange color, which is a result of the
dure, below]. Regardless of the particular approach followed, the high intracellular lipid content. The glands have a fibrous capsule
keys to successful adrenalectomy are the same: proper patient but are relatively fragile and can be easily cracked or fragmented
selection for operation, a solid understanding of adrenal patho- with surgical manipulation.
physiology, and a thorough knowledge of adrenal anatomy.
RIGHT ADRENAL
a b
Stomach
Liver
Liver
Spleen
Left
Adrenal Adrenal
Tumor Inferior
Vena
Cava
Kidney
Duodenum Left
Kidney
Vena Cava
Pancreas
Colon
Right Left
Right Inferior
Right Superior Phrenic Artery Left Superior
Adrenal Artery Adrenal Artery
Left Inferior
Right Middle Phrenic Artery
Adrenal Artery
Left Inferior
Adrenal Artery
Left Adrenal
Vein
Figure 2 Depicted is the adrenal blood supply. Multiple adrenal arteries are present; a single
central adrenal vein drains into the IVC on the right side and the renal vein on the left side.
upper pole of the kidney. The diaphragm forms the posterior and medial to the adrenal and usually joins the left adrenal vein cepha-
lateral boundaries of the gland. lad to its junction with the renal vein.
The blood supply of the right adrenal is derived from branches
of the inferior phrenic artery, the right renal artery, and the aorta
[see Figure 2]. Typically, multiple small branches enter the gland Preoperative Evaluation
along its superior, medial, and inferior aspects. Arterial branches
INDICATIONS FOR OPERATION
from the aorta generally course posterior to the vena cava before
entering the adrenal. Each adrenal is drained by a single central The main indications for adrenalectomy are well established [see
vein. On the right, this vein is short (1 to 1.5 cm long), runs trans- Table 1]. Any adrenal lesion that either is hypersecretory for one of
versely, and joins the lateral aspect of the inferior vena cava. In
some cases, a more superiorly located accessory adrenal vein may
enter either the IVC or one of the hepatic veins. Control of the Table 1Indications for Adrenalectomy
adrenal vein is the most critical aspect of right adrenalectomy, in
that the short course of this vessel makes it susceptible to tearing or Aldosteronoma
avulsion from the IVC. Cushing syndrome
Cortisol-producing adenoma
LEFT ADRENAL Primary adrenal hyperplasia
Failed treatment of ACTH-dependent Cushing syndrome
The spleen and tail of the pancreas overlie the anterior and
Pheochromocytoma
medial borders of the left adrenal. The inferolateral aspect of the
Sporadic or familial
gland lies over the superomedial aspect of the left kidney, to which Malignant pheochromocytoma
it is more closely applied than the right adrenal is to the right kid- Nonfunctioning incidental lesion
ney. The inferior aspect of the adrenal is in close proximity to the 45 cm or atypical radiologic appearance
renal vessels, especially the renal vein. As on the right side, the pos- Adrenal metastasis
terior aspect of the adrenal rests on the diaphragm. Solitary, unilateral in the absence of extra-adrenal cancer
The arterial blood supply of the left adrenal is similar to that of Adrenal cortical carcinoma
the right adrenal [see Figure 2].The left adrenal vein is longer than Adrenal sarcoma
the right adrenal vein and runs somewhat obliquely from the infer- Adrenal myelolipomas (only if symptomatic or enlarging)
Miscellaneous other lesions (atypical cysts, ganglioneuromas)
omedial aspect of the gland to enter the left renal vein.The inferi-
or phrenic vein courses in a superior-to-inferior direction just
2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 26 Adrenalectomy 3
the adrenal hormones or appears to be malignant or possibly malig- malignant or difficult-to-control hypertension should be screened
nant should be removed. In selected cases, it may be appropriate to for this diagnosis. Screening consists of measuring plasma aldos-
remove adrenal metastases if they are solitary and if there is no evi- terone concentration (PAC) and plasma renin activity (PRA). A
dence of extra-adrenal metastatic disease. Nonfunctioning adrenal PAC-to-PRA ratio higher than 20 to 30, in conjunction with a
lesions that appear to be benign on the basis of their size (< 4 cm) and plasma aldosterone concentration higher than 15 ng/dl, is sugges-
their appearance on computed tomography or magnetic resonance tive of the diagnosis and should be confirmed by measuring 24-
imaging need not be removed unless they enlarge during follow-up. hour urine aldosterone levels while the patient is on a high-sodi-
Adrenal myelolipomas and cysts usually can be diagnosed radio- um diet.2 A 24-hour urine aldosterone level higher than 12 g/24
graphically and should not be removed unless they cause symptoms. hr in this setting is confirmatory.
Most of the conditions for which adrenalectomy is indicated are Because 25% or more of cases of primary hyperaldosteronism
amenable to a laparoscopic approach. However, the role of lap- may be idiopathic as a result of bilateral adrenal hyperplasia and
aroscopy in patients with large adrenal tumors (> 6 to 8 cm) or should therefore be managed medically and not surgically, the next
potentially malignant primary adrenal lesions remains controver- step should be imaging with thin-section (3 mm cuts) CT or MRI.
sial. In the presence of a locally invasive tumor, a laparoscopic The finding of a discrete unilateral adenoma larger than 1 cm on CT
approach is contraindicated because of the need to perform en in conjunction with a normal contralateral adrenal is sufficient local-
bloc resection of the tumor and any adjacent involved structures. ization to allow the surgeon to proceed with adrenalectomy. If CT
shows bilateral nodules, bilateral normal adrenals, or a unilateral
COMMON ADRENAL TUMORS
nodule smaller than 1 cm, then adrenal vein sampling for aldos-
A brief review of the pertinent clinical and biochemical features terone and cortisol should be done to determine whether a unilater-
of the various hypersecretory adrenal tumors [see Table 2] will facil- al gradient of increased aldosterone production exists.3
itate evaluation of adrenal lesions (including adrenal incidentalo-
mas) and planning for adrenal surgery. Cortisol-Producing Adenoma
Approximately 20% of cases of Cushing syndrome are related
Aldosteronoma to increased production of cortisol by an adrenal cortical tumor.
Primary hyperaldosteronism is the most common form of sec- Adrenal Cushing syndrome is most commonly attributable to ade-
ondary hypertension, and aldosterone-producing adenoma is the noma but may also result from adrenal cortical carcinoma or pri-
most common hypersecretory adrenal tumor. The prevalence of mary adrenal hyperplasia.The classic features of full-blown Cushing
this diagnosis is much higher than was previously thought,1,2 syndrome are usually obvious and include centripetal obesity, moon
reaching levels as high as 12% of hypertensive individuals in some facies, hypertension, purple skin striae, proximal muscle weakness,
series.1 The classic finding in primary hyperaldosteronism is hy- osteopenia, and amenorrhea. Not all patients present with ad-
pertension in conjunction with hypokalemia, but many patients vanced clinical signs, however, and the high prevalence of hyper-
have a normal or low-normal serum potassium level. Therefore, tension and obesity in the general population necessitates liberal
any patient who becomes hypertensive at an early age or who has use of diagnostic testing.
Adrenal cortical carcinoma Cushing syndrome, virilizing features, 24-hr urinary free cortisol and metabolites
CT of chest/abdomen/pelvis
local pain or mass Plasma DHEA-sulfate
Step 3: mobilization and detachment of specimen. Once the Figure 5 Laparoscopic right adrenalectomy: transabdominal
adrenal vein is divided, dissection is continued superiorly and infe- approach. Depicted is the anatomic exposure for right adrenalec-
riorly with the L-hook cautery. The numerous small arteries that tomy. The liver is retracted medially, and the right triangular liga-
enter the gland at its superior, medial, and inferior margins can be ment of the liver is divided with an L-hook electrocautery.
2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 26 Adrenalectomy 7
a b
inferior pole of the spleen and away from the left kidney. Next, the often necessary to clip the inferior phrenic vein again as the dis-
splenorenal ligament is incised from the inferior pole of the spleen section proceeds more proximally.
to the diaphragm to allow full medial rotation of the spleen and
provide access to the left retroperitoneum [see Figure 7]. It is Step 3: mobilization and detachment of specimen. Once the left
important not to dissect lateral to the kidney; doing so will cause adrenal vein has been securely clipped and divided, the dissection
the kidney to tilt forward and will interfere with exposure. Once is continued cephalad along both the lateral and the medial bor-
the spleen is completely mobilized, it should fall medially, with ders of the gland. Because of the surrounding retroperitoneal fat,
minimal or no retraction needed to keep it out of the operative it is advisable to use the ultrasonic coagulator for this part of the
field. Division of the ligaments can be accomplished more quick- left-side dissection. Because the left adrenal is more flattened out
ly and with less bleeding if an ultrasonic coagulator is used. on the superomedial aspect of the left kidney than the right adren-
At this point in the dissection, the tail of the pancreas should be al is on the right kidney, more of the kidney will be exposed dur-
visible, along with the splenic artery and vein. The plane between ing dissection in a left adrenalectomy than in a right adrenalecto-
the pancreas and the left kidney is then developed. The adrenal is my. Finally, the posterior and superior attachments to the diaph-
located on the superomedial aspect of the kidney just cephalad to ragm and the retroperitoneal fat are divided.
the tail of the pancreas and should be visible at this point unless
there is a great deal of retroperitoneal fat (as is often the case in Step 4: extraction of specimen. Once the gland is free, the
patients with Cushing syndrome). If the adrenal gland is not read- retroperitoneum is inspected and the specimen extracted as in a
ily visible, laparoscopic ultrasonography should be employed to right adrenalectomy. If there is any possibility that the pancreatic
help locate it and to delineate the surrounding anatomy, particu- parenchyma may have been violated, a closed suction drain is left
larly the upper kidney and the renal hilar vessels. If the dissection in place.
starts too low, the renal hilar vessels or the ureter could be injured.
Once the adrenal is visualized, the medial and lateral borders Retroperitoneal Approach
are usually defined by means of dissection with the hook cautery Retroperitoneal endoscopic adrenalectomy can be carried out
and division of areolar attachments and small vessels. The dissec- with the patient in either a lateral or a prone position. In general,
tion is then continued inferiorly to locate the adrenal vein as it exits this technique is more challenging to learn than transabdominal
the inferomedial border of the gland [see Figure 8]. The inferior adrenalectomy, the working space is more cramped, and it is easi-
border of the adrenal often sits adjacent to the left renal vein, from er for surgeons to become disoriented unless they have experience
which it can be separated by means of gentle blunt dissection and working in the retroperitoneum. On the other hand, the retroperi-
judicious use of the electrocautery. toneal approach allows surgeons to avoid having to reposition
patients for bilateral adrenalectomy (if the prone position is used),
Step 2: isolation, clipping, and division of left adrenal vein. Once and it may simplify access in patients who have previously under-
the adrenal vein has been visualized, it is isolated, doubly clipped, gone extensive upper abdominal procedures.
and divided. Because the adrenal vein is usually joined by the infe- Initial access is usually achieved through open insertion of a 12
rior phrenic vein cephalad to its junction with the renal vein, it is mm port into the retroperitoneum either (1) just lateral or inferi-
2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 26 Adrenalectomy 8
Liver b
Spleen
A
Left
Kidney
Pancreas
or to the tip of the 12th rib (for the prone position) or (2) in the costal space and through the diaphragm, provides excellent expo-
midaxillary line about 3 cm above the iliac crest (for the lateral sure but is associated with increased incision-related morbidity
position). A potential advantage of the lateral approach is that it and is rarely used.
can be converted to a transperitoneal approach if difficulty is Much of the exposure and dissection is the same as in a laparo-
encountered. scopic adrenalectomy; however, because open adrenalectomy is
Once the retroperitoneum is entered, a balloon device is often employed for removal of particularly large tumors, some
deployed to create an initial working space, which is further devel- additional maneuvers may be necessary to achieve adequate expo-
oped by means of CO2 insufflation and blunt dissection.The sec- sure and vascular control. For example, it may be helpful to ele-
ond and third ports are then placed [see Figure 9]. The principles vate the flank with a roll or a bean-bag mattress and then flex the
of dissection are the same as in a transabdominal adrenalectomy operating table to open up the space between the costal margin
[see Transabdominal Approach, above]. Laparoscopic ultrasonog- and the iliac crest. Once the abdomen is entered, exploration is
raphy may be useful for defining the upper portion of the kidney carried out for the presence of metastatic disease.
and the adrenal gland and tumor. Exposure of the adrenal on the right side is achieved by divid-
ing the right triangular ligament of the liver, as in the laparoscop-
OPEN ADRENALECTOMY
ic approach.The hepatic flexure of the colon is also reflected infe-
Of the four approaches to open adrenalectomy [see Operative riorly. With large tumors, a Kocher maneuver should be per-
Planning, Choice of Procedure, above], the anterior transabdomi- formed to afford better exposure of the vena cava and the renal
nal approach is the preferred method for any tumors that are too vessels. The remainder of the dissection proceeds in much the
large to be removed laparoscopically and for all invasive adrenal same manner as in a laparoscopic right adrenalectomy. For sus-
malignancies. The incision most commonly used is an extended pected adrenal malignancies, a wide resection should be carried
unilateral or bilateral subcostal incision, though a midline incision out, with removal of periadrenal fat and lymphatic tissue and any
is also an option [see Figure 10]. The extended subcostal incision suspicious lymph nodes. For tumors that appear to involve the
yields exposure of both adrenal glands, as well as the rest of the vena cava, vascular control of both the IVC proximal and distal to
peritoneal cavity. If necessary, it may be extended superiorly in the the tumor and the renal veins should be achieved before the lesion
midline to the xiphoid to provide better upper abdominal expo- is removed.
sure for full mobilization of the liver and access to the hepatic veins Open left adrenalectomy entails mobilization of the splenic flex-
and the vena cava.The exposure obtained with this incision is suf- ure of the colon and division of the splenorenal ligament. The
ficient for all but the most extensive adrenal malignancies. If the spleen, the tail of pancreas, and the stomach are reflected medial-
tumor involves the vena cava, the incision may be extended into a ly en bloc to expose the left kidney and the left adrenal. The left
median sternotomy to provide access to the superior vena cava adrenal vein is ligated with clips or silk ties near its junction with
and the heart. The classic thoracoabdominal incision, which the renal vein. The remainder of the dissection proceeds as in a
extends from the abdomen up through the seventh or eighth inter- laparoscopic left adrenalectomy. For left-side primary adrenal
2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 26 Adrenalectomy 9
A
PV
AV
malignancies, periaortic lymphatic vessels and lymph nodes should ing risk include obtaining good exposure of the operative field and
be removed along with the specimen. If a large left-side tumor is employing meticulous dissection and gentle handling of the
invading adjacent structures, removal may require en bloc resec- adrenal and surrounding structures.When bleeding does occur, it
tion of the spleen, the distal pancreas, and the kidney. may be from the adrenal veins, the adrenal gland itself, the IVC,
the renal veins, the liver, the pancreas, the spleen, or the kidney.
For bleeding during laparoscopic adrenalectomy, the first maneu-
Troubleshooting ver should be to tamponade the bleeding site with an atraumatic
instrument. If this maneuver is successful, dissection should be
INABILITY TO LOCATE ADRENAL
directed away from the bleeding site for a while, until better expo-
The adrenal is usually not difficult to find on the right side, sure of the area can be obtained. Major hemorrhage from the IVC
where it should be visible once the right hemiliver has been mobi- or the renal veins that is not immediately controlled should be
lized. Important landmarks on that side are the IVC, which is managed by prompt conversion to open adrenalectomy (see
medial to the adrenal, and the kidney, which is inferior to the below). Lesser bleeding may also be an indication for conversion
adrenal. Once these structures have been identified, the location to open adrenalectomy if it obscures the tissue planes and thereby
of the adrenal should be apparent. In contrast, the adrenal can be increases the risk of inadvertent entry into the adrenal gland or
difficult to find on the left side, especially if the tumor is small or tumor.
the patient is obese.To locate the left adrenal, the splenorenal lig-
CONVERSION TO OPEN ADRENALECTOMY
ament should be fully divided, and then the plane between the
kidney and the tail of the pancreas should be developed, with the Conversion to open adrenalectomy may sometimes be neces-
tail of the pancreas rotated medially. As dissection proceeds supe- sary because of bleeding, failure to progress with the dissection, or
riorly, the adrenal can be visually distinguished from the retroperi- a locally invasive tumor. If the patient is in the lateral decubitus
toneal fat by its golden-orange appearance. If the adrenal is not yet position, conversion may be accomplished by means of a subcostal
visualized at this point, laparoscopic ultrasonography should be incision extended into the flank. With the patient on a bean-bag
used to verify the locations of the superior pole of the left kidney mattress, the operating table can be rotated out of the straight lat-
and the renal vessels. Ultrasonography should also be able to eral plane so that the patient comes to occupy more of a hemilat-
image the adrenal gland and tumor within the retroperitoneal fat eral position. If the procedure is a bilateral adrenalectomy, then
[see Figure 11]. either a bilateral subcostal incision or a midline incision may be
employed after the patient has first been returned to more of a
BLEEDING
supine position. For this reason, it is important to extend the ini-
The best means of managing bleeding problems during adrenal- tial preparation and draping past the midline of the abdomen.
ectomy is prevention. Important measures for minimizing bleed- Alternatively, if the conversion is not being done on an urgent
2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 26 Adrenalectomy 10
basis because of bleeding, the port sites may be closed, and the
patient may then be moved into the supine position, reprepared,
and redraped.
An option that may be considered before conversion to an open
procedure is the use of a hand access port. A hand-assisted tech-
nique may be particularly useful for larger, noninvasive tumors that
are harder to manipulate with laparoscopic instruments.The loca-
tion of the incision for the hand port may vary according to the
patients body habitus; generally, however, an ipsilateral subcostal
location medial to the working ports allows adequate hand access
while preserving visualization through the more lateral ports.
LARGE TUMORS
minimally invasive surgical technique. In some of the cases, how- lished. Rates of conversion to open adrenalectomy in high-volume
ever, the pattern of recurrence, characterized by the development centers have ranged from 3% to 13%, and operating times have av-
of multiple intraperitoneal or port site metastases, suggested that eraged 2 to 3 hours.9,11,18-23 Most patients are now discharged from
laparoscopic dissection and pneumoperitoneum might have con- the hospital within 24 to 48 hours after operation. Although no
tributed to tumor spread.13-16 One group treated three patients for prospective, randomized trial comparing laparoscopic with open
recurrent pheochromocytomatosis that developed after laparo- adrenalectomy has been carried out, several retrospective studies
scopic adrenalectomy.17 These patients were found to have multi- have consistently shown that the laparoscopic approach is associat-
ple small tumor nodules in the adrenalectomy bed during open ed with decreased pain, a shorter hospital stay, and a faster recov-
reoperation after removal of apparently benign pheochromocy- ery.24-27 Complication rates have also been low, and overall, compli-
tomas. Fragmentation of the tumor and excessive tumor manipu- cations appear to be less common than with open adrenalectomy.10
lation during the laparoscopic dissection were considered the The results of a laparoscopic approach in patients with large
probable mechanisms of tumor recurrence. (> 6 cm) adrenal tumors or malignant primary or metastatic
These reports highlight the need for caution in approaching large, adrenal lesions have been reviewed28; generally, the conversion
malignant, or potentially malignant adrenal tumors. Surgeons who rates for large or malignant tumors have been higher than those
attempt a laparoscopic approach in this setting should be highly ex- reported in other laparoscopic adrenalectomy series. Overall, tumor
perienced in laparoscopic adrenalectomy techniques, and the tumor recurrence rates after laparoscopic adrenalectomy have been low.29-33
should be well circumscribed and not locally invasive.The use of a In one series, however, local or regional tumor recurrence devel-
hand port may be a valuable adjunct to resection in these cases. Re- oped in three of five patients with adrenocortical carcinomas that
gardless of the specific surgical approach followed, wide excision of were treated laparoscopically.34 Other groups have also published
the lesion along with the surrounding periadrenal fat is crucial for anecdotal reports of local tumor recurrences after resection of
minimizing recurrence rates in this population. unsuspected adrenal carcinomas.13-16 Whether these recurrences
were related primarily to the surgical technique employed or to the
underlying tumor biology is unclear. It would appear, therefore,
Outcome Evaluation that in most cases, primary adrenal malignancies are best approach-
The safety and efficacy of laparoscopic adrenalectomy for the re- ed in an open fashion unless the tumor is small and well circum-
moval of small, benign adrenal tumors have been clearly estab- scribed and the surgeon is highly experienced.
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