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Laparoscopic Adrenalectomy

The adrenal glands are two small, wedge shaped glands that rest above the upper inside edge of the kidneys in the retroperitoneum, the tissues behind the organs of the abdominal cavity. These glands produce hormones that have important functions in controlling the blood pressure and in controlling how much salt and water are in the circulation.

They are also the body’s only source of cortisone, another hormone that has a critical role in normal cell function. Usually, only one normal adrenal gland is necessary for satisfactory adrenal function.

Surgical removal of the adrenal glands is undertaken for a number of reasons. On occasion, tumors develop in the adrenal glands and the gland and tumor must be removed. Sometimes this is to prevent progression to cancer, or to treat early cancers.

Some benign tumors produce large amounts of hormones normally produced by the adrenal but since there is an excess of hormone, patients can suffer the effects of excessive hormone. Examples include a cortisone-secreting tumor leading to Cushing’s syndrome, aldosterone secreting tumor leading to low potassium and hypertension, or epinephrine-secreting tumors called pheochromocytoma that are also associated with unpredictable but potentially dangerous levels of hypertension. Removal of the gland and tumor in each of these situations is curative, except in malignant tumors where there is always a chance of spread.

Traditional techniques for adrenalectomy on either the right or the left require a large anterior abdominal wall incision with a prolonged recovery. An approach through the back, opening and splitting the space around the 11th or 12th ribs through a smaller incision has also been developed and while effective, appears to have an increased incidence of persistent side effects, especially hernia formation and pain.

The most recent technical innovations with respect to the surgical management of adrenal disease are videoendoscopic approaches to the adrenal gland. One approach used by some surgeons is to create a space around the adrenal gland with an air-filled balloon inserted retroperitoneally. This minimizes trauma to organs within the peritoneal cavity but for most surgeons doing laparoscopic adrenalectomy, the common approach is through the flank, across the peritoneal space to the adrenal gland.

For the left adrenal gland, the patient is placed right side down and secured in this position while under general anesthesia. Laparoscopic ports to insert a camera and instruments (3 or 4 ports usually) are positioned below the left rib cage. Exposure of the adrenal gland requires that the spleen be freed up from attachments over the adrenal, the colon be moved down, and the tissue over the upper pole of the kidney opened to reveal the adrenal gland.

Care must be taken to avoid injury to the pancreas at this point. Once identified, the adrenal, which measure about 2 inches on each side, is dissected from surrounding fatty tissue and arterial blood vessels into the gland, and a large vein leading out of the gland, are progressively divided between metal clips so that the gland and contained tumor can be removed through one of the port sites.

This technique has been very successfully applied at a number of centers around the United States. Prior surgery in the area, obesity, proven malignancy, intolerance of the laparoscopic position or technique, and some very large tumors have proven to be contraindications to the technique.

For the right adrenal gland, the patient is again positioned so that other organs are pulled away by gravity. Thus, the patient is placed under anesthesia and rolled so that the left side is down. Laparoscopic ports (4-5) are inserted along the right rib cage for camera, instruments, and often a liver retractor. On the left, mobilizing the spleen was important. On the right, mobilizing the right lobe of the liver from the tissues of the back of the abdomen is critical.

Who is a Candidate For Laparoscopic Adrenalectomy?

• Tumors less than 10 cm in diameter (~ 4 inches). Tumors larger than this are more likely to be cancerous and therefore require better exposure and a more aggressive operation. Tumors larger than this also pose a technical problem because the surgeon has difficulty seeing around it with the camera.
• Tumors which secrete hormone. These masses are ideally suited for this approach.
• Pheochromocytomas. Pheochromocytomas are tumors which arise from the central zone of the adrenal gland (the medulla) and secrete epinephrine (adrenaline). Since they are usually small and benign, they can be removed with great success using this minimally invasive approach.
• Tumors which do not secrete hormone...if they are greater than 4 cm (~ 1 3/4 inches). Laparoscopic adrenalectomy is the perfect approach to these masses which would otherwise necessitate numerous repeated CAT scans and often life-long follow-up by a physician.
• Tumors which have NO characteristics of malignancy. Laparoscopic removal of the adrenal gland is not appropriate for any cancerous tumors or those which have clinical / radiologic characteristics of malignancy.