Laparoscopic Adrenalectomy as a Management for Benign Suprarenal Tumors

Abstract

Before the era of laparoscopic procedures, conventional open adrenalectomy was the only surgical approach to adrenal neoplasms. Since the introduction of laparoscopic adrenalectomy by Gagner et al. in 1992, the majority of benign adrenal lesions have been removed by various laparoscopic techniques. The decision to utilize open versus laparoscopic approach should be based on body habitus of the patient, the specific type and characteristics of the tumor and the experience of the surgeon. The modalities of choice in the evaluation of an adrenal mass are computed tomography (CT) scanning, magnetic resonance imaging (MRI), and positron emission tomography (PET) scanning. Ultrasonography has a role in the evaluation of a potential adrenal mass in infants, but no appearance is specific for benign adrenal adenoma. Laparoscopic adrenalectomy is indicated in: • Endocrine active tumors (aldosteronoma, Cushing syndrome, pheochromocytomas and sex hormone producing tumors) • Nonfunctioning adrenal masses larger than 4-6 cm. • Nonfunctioning adrenal masses with progressive growth. • Suspected small malignancies (primary and metastatic). • Solitary adrenal metastasis with negative metastatic survey. • Other uncommon indications included angiomyolipoma, lymphoma, and macronodular hyperplasia.

Advantages of laparoscopic surgery include: • The risk of bleeding during surgery is reduced. • The smaller incision size also reduces the risk of pain and bleeding after surgery. • The smaller incision also leads to the formation of a significantly smaller scar after surgery. • Exposure of the internal organs to external contaminants is significantly reduced. • The length of hospital stay required is significantly shorter with laparoscopic surgery. Lateral transabdominal approach (LTA) seems to be the technique of choice for most surgeons. Compared with the retroperitoneal approach, LTA is much easier, allows large operative field, lateral decubitus position affords good exposure as gravity pulls the intra-abdominal contents outside the operative field, provides confident hemostatic dissection through clear recognition of the many anatomic landmarks in the abdominal cavity, enables the adrenal vein to be dissected early, suitable for large tumors (more than 6 cm) and has access to the intra-abdominal cavity which is useful for evaluation. LTA is limited in case of prior extensive abdominal surgery. Particularly for pheochromocytomas, which are commonly more technically demanding resections due to the increased vascularity and inflammatory process surrounding the adrenal gland, comparative studies have reported lower EBL and hospital stay for the laparoscopic technique. Operative duration, morbidity, and mortality were found to be similar in the majority of published studies. Additionally, most studies reported equal results of the two surgical techniques on intraoperative patient hemodynamics, while some have reported fewer episodes of intraoperative hypertension or hypotension when the laparoscopic technique was used. A robotic radical adrenalectomy results in significantly less blood loss during surgery, reducing the need for blood transfusions, and less post-operative pain and scarring. The robotic procedure’s small incisions avoid the need for a large, disfiguring scar, resulting in significantly less post-operative discomfort, minimal surface scarring, shorter hospital stay and faster recovery. Most patients undergoing robotic radical adrenalectomy leave the hospital in 1 to 3 days versus 3 to 5 days for open surgery, and are able to resume normal activities within 1 to 2 weeks, compared to 4 to 6 weeks for open surgery.