Indications

The indications are similar to open adrenalectomy and include all hormonally active tumors (aldosteronoma, pheochromocytoma, cortisol producing adenoma, virilizing adenoma), bilateral adrenal hyperplasia secondary to Cushing's disease or ectopic ACTH production, symptomatic angiomyolipomas and cysts, and incidentalomas. Historically, pheochromocytoma was an indication for an open anterior approach to allow the surgeon to explore both adrenals and search for extra-adrenal tumors. However, modern imaging techniques (CT, MRI, MIBG) allow for more precise localization thereby facilitating the unilateral laparoscopic approach. Nonfunctioning adrenal masses (incidentalomas) can also be approached laparoscopically unless there is preoperative evidence of malignant invasion into contiguous structures. All surgeons would recommend laparoscopic adrenalectomy for incidentalomas greater than 6 cm in size because there is a 15% risk of malignancy (13). This risk diminishes considerably for tumors less than 6 cm. However, there have been several reports of adrenocortical carcinoma even in tumors less than 3.2 cm (14, 15). Therefore, we feel that any incidentaloma greater than 3 cm should be excised in otherwise young and fit individuals.

Contraindications

Malignancy is the only absolute contraindication to laparoscopic adrenalectomy. This includes adrenocortical carcinoma and pheochromocytoma with nodal or metastatic involvement. The exception to this rule is the resection of metastases to the adrenal when the primary is controlled. Other relative contraindications include coagulopathy, prior laparotomy and size greater than 15 cm.

Results

Since it inception in 1992 over 1000 cases of laparoscopic adrenalectomy have been reported in the literature. Unfortunately, there have been no prospective randomized studies evaluating this new technique. There is, however, considerable evidence as to the safety and efficacy of laparoscopic adrenalectomy. Table I shows a summary of published series that consisted of greater than twenty laparoscopic adrenalectomies (4–8, 11, 12, 15, 17, 20–38). These series were reported from 1995 to 1999 and represent 27 authors and 1052 patients. A total of 1082 adrenalectomies were performed which included 30 bilateral resections. The age ranged from 17 to 84 and the male to female ratio was approximately 1 to 1. The size of the lesions varied from 0.5 cm up to 14 cm. The lateral transperitoneal approach (88% of patients) was more common than the posterior retroperitoneal approach. The conversion rate ranged from 0% to 18%. Most lesions (98%) were totally resected but a few recent reports of subtotal adrenalectomy (22 cases) suggest this as yet another option (37). The most common indication was aldosteronoma (42.7%), then Cushing's syndrome (18.6%), incidentaloma (16.9%), and pheochromocytoma (14.7%). There were several other less common indications such as angiomyolipoma, small carcinomas or metastases, virilizing adenomas, and macronodular hyperplasia.

Table I

Series of laparoscopic adrenalectomies.

Although there have not been any prospective randomized trials comparing the laparoscopic and the open approach, there have been several retrospective studies (4–6, 8–12, 39–41). The results of these are summarized in table II. Operating time was shorter in the open groups with an average of 149 minutes compared to 195 minutes for the laparoscopic groups. However, there was great variability ranging from an average of 116 minutes to 289 minutes for the laparoscopic approach. Some of this variability can be explained by a learning curve. For example, Winfield had an average operating time of 219 minutes for the first 21 cases, but the last 10 averaged only 160 minutes (6). Rutherford, who has performed the greatest number of laparoscopic resections for aldosteronomas, averaged 152 minutes for the first 20 cases but this dropped to only 109 minutes for the last 40 cases (28). Estimated blood loss (EBL) appears to be less in the laparoscopic groups with an average of 153cc compared to 355cc for the open groups. Analgesic requirements were also considerably less (4–6, 10, 12, 42). One of the most dramatic findings is the length of hospital stay (LOS). In the open groups this varied from 4.5 days to 9 days, with an average of 6.55 days across all groups. The laparoscopic groups ranged from 1.7 to 3.4 days with an average of 2.57 days. Length of time to full recovery was also noted to be less by several authors (4–6, 9, 11).

Table II

Laparoscopic versus open adrenalectomy.

Complications were less for the laparoscopic groups with an average rate of 7% versus 24%. The most common complication in the laparoscopic groups was postoperative hematoma or need for transfusion with an approximate rate of 3%. Wound complications, pulmonary complications and DVT were all less than 1%. In the open group respiratory complications such as pneumonias or atelectasis were most frequent with a rate of about 6%. Wound infections were reported in 3% and hematomas and transfusion requirements in 3%. There was also a splenectomy and splenic injury rate of 1.5%. Interestingly, Thompson et al. also noted a dramatic late complication rate of 54% for open posterior adrenalectomy (4). These complications consisted of chronic pain in 14%, flank numbness in 10% and muscle laxity in 30%. Therefore it appears justified to state that the morbidity of laparoscopic adrenalectomy is definitely less than that for the open procedure.

The retroperitoneoscopic approach to the adrenal gland was first described by Mercan et al. in 1995 (3). Since that time many surgeons have learned the technique and published their results. More recently, several surgeons have performed retrospective comparisons of the transperitoneal versus the retroperitoneal approaches (16–19, 21, 43). These are summarized in table III. There was no significant difference in operating time, blood loss or length of stay. Surgeons who perform both approaches feel that although the outcomes are similar, each has a specific advantage (17). The retroperitoneal approach can avoid intraperitoneal adhesions from previous operations and can save time in bilateral adrenalectomies as the patient does not need to be repositioned. However, the retroperitoneal approach is more difficult to learn because of the lack of familiarity with the anatomy, and the working space is smaller so the technique can only be applied to small tumors.

Table III

Transperitoneal versus retroperitoneal approach.

Laparoscopic adrenalectomy appears to have established itself as the standard of care for most adrenal neoplasms. The open anterior approach still has a place for very large tumors and obvious malignancy, but the open posterior approach has essentially been supplanted. The choice of transperitoneal versus retroperitoneal is at present determined primarily by surgeon preference except in larger tumors where the transperitoneal approach is clearly superior.

References

1.

Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing's syndrome and pheochromocytoma [letter] N Engl J Med. (1992);327(14):1033. [PubMed: 1387700]

2.

Gagner M et al (1993), Early experience with laparoscopic approach for adrenalectomy. Surgery 114 (6): 1120–1124; discussion 1124–1125 . [PubMed: 8256217]

3.

Mercan S et al (1995) Endoscopic retroperitoneal adrenalectomy. Surgery 118 (6): 1071–1075; discussion 1075–1076 . [PubMed: 7491525]

4.

Thompson G B. et al. Laparoscopic versus open posterior adrenalectomy: a case-control study of 100 patients. Surgery. (1997);122(6):1132–1136. [PubMed: 9426429]

5.

Vargas H I. et al. Laparoscopic adrenalectomy: a new standard of care. Urology. (1997);49(5):673–678. [PubMed: 9145969]

6.

Winfield H N. et al. Laparoscopic adrenalectomy: the preferred choice? A comparison to open adrenalectomy. J Urol. (1998);160(2):325–329. [PubMed: 9679870]

7.

Schell S R, Talamini M A, Udelsman R. Laparoscopic adrenalectomy for nonmalignant disease: improved safety, morbidity, and cost-effectiveness. Surg Endosc. (1993);13(1):30–34. [PubMed: 9869684]

8.

Staren ED, Prinz RA (1996) Adrenalectomy in the era of laparoscopy. Surgery 120 (4): 706–709; discussion 710–711 . [PubMed: 8862381]

9.

MacGillivray D C. et al. A comparison of open vs. laparoscopic adrenalectomy. Surg Endosc. (1996);10(10):987–990. [PubMed: 8864091]

10.

Linos D A. et al. Anterior, posterior, or laparoscopic approach for the management of adrenal diseases? Am J Surg. (1997);173(2):120–125. [PubMed: 9074377]

11.

Guazzoni G. et al. Transperitoneal laparoscopic versus open adrenalectomy for benign hyperfunctioning adrenal tumors: a comparative study [see comments] J Urol. (1995);153(5):1597–1600. [PubMed: 7714980]

12.

Brunt L M. et al. Laparoscopic adrenalectomy compared to open adrenalectomy for benign adrenal neoplasms [see comments] J Am Coll Surg. (1996);183(1):1–10. [PubMed: 8673301]

13.

Staren E D, Prinz R A. Selection of patients with adrenal incidentalomas for operation. Surg Clin North Am. (1995);75(3):499–509. [PubMed: 7747255]

14.

Linos DA, Stylopoulos N, Raptis SA (1996) Adrenaloma: a call for more aggressive management. World J Surg 20 (7): 788–792; discussion 792–793 . [PubMed: 8678952]

15.

Chapuis Y, Maignien B, Abboud B. [Adrenalectomy under celioscopy. Experience of 25 operations] Presse Med. (1995);24(18):845–848. [PubMed: 7638115]

16.

Bonjer H J. et al. Comparison of three techniques for adrenalectomy. Br J Surg. (1997);84(5):679–682. [PubMed: 9171764]

17.

Duh QY et al (1996) Laparoscopic adrenalectomy. Comparison of the lateral and posterior approaches. Arch Surg 131 (8): 870–875; discussion 875–876 . [PubMed: 8712912]

18.

Baba S. et al. A posterior lumbar approach for retroperitoneoscopic adrenalectomy: assessment of surgical efficacy. Urology. (1997);50(1):19–24. [PubMed: 9218013]

19.

FernandezCruz L et al (1996) Laparoscopic unilateral and bilateral adrenalectomy for Cushing's syndrome. Transperitoneal and retroperitoneal approaches. Ann Surg 224 (6): 727–734; discussion 734–736 . [PMC free article: PMC1235468] [PubMed: 8968227]

20.

Miyake O. et al. Laparoscopic adrenalectomy. Comparison of the transperitoneal and retroperitoneal approach. Eur Urol. (1998);33(3):303–307. [PubMed: 9555557]

21.

Takeda M. et al. Retroperitoneal laparoscopic adrenalectomy for functioning adrenal tumors: comparison with conventional transperitoneal laparoscopic adrenalectomy [see comments] J Urol. (1997);157(1):19–23. [PubMed: 8976206]

22.

Suzuki K. et al. Laparoscopic adrenalectomy: clinical experience with 12 cases [see comments] J Urol. (1993);150(4):1099–1102. [PubMed: 8371362]

23.

Miccoli P. et al. Laparoscopic adrenalectomy. J Laparoendosc Surg. (1995);5(4):221–226. [PubMed: 7579673]

24.

Nakagawa K. et al. Laparoscopic adrenalectomy: clinical results in 25 patients. J Endourol. (1995);9(3):265–267. [PubMed: 7550271]

25.

Heintz A, Walgenbach S, Junginger T. Results of endoscopic retroperitoneal adrenalectomy. Surg Endosc. (1996);10(6):633–635. [PubMed: 8662396]

26.

Henry J F. et al. [Laparoscopic surgery of adrenal glands: indications and limits] Ann Endocrinol. (1996);57(6):520–525. [PubMed: 9084699]

27.

Marescaux J, Mutter D, Wheeler M H. Laparoscopic right and left adrenalectomies. Surgical procedures. Surg Endosc. (1996);10(9):912–915. [PubMed: 8703150]

28.

Rutherford JC et al (1996) Laparoscopic adrenalectomy. World J Surg 20 (7): 758–760; discussion 761 . [PubMed: 8678947]

29.

Suzuki K. et al. [Laparoscopic adrenalectomy. Experiences with 50 patients] Urologe A. (1996);35(3):233–237. [PubMed: 8711830]

30.

Ushiyama T. et al. [Laparoscopic adrenalectomy for Cushing's syndrome: a study of comparisons between laparoscopic and open adrenalectomy, and laparoscopic adrenalectomy for differing adrenal tumors] Nippon Hinyokika Gakkai Zasshi. (1996);87(7):986–991. [PubMed: 8776965]

31.

de Canniere L. et al. Multicentric experience of the Belgian Group for Endoscopic Surgery (BGES) with endoscopic adrenalectomy. Surg Endosc. (1997);11(11):1065–1067. [PubMed: 9348374]

32.

Gagner M et al (1997) Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures. Ann Surg 226 (3): 238–246; discussion 246–247 . [PMC free article: PMC1191015] [PubMed: 9339930]

33.

Terachi T. et al. Transperitoneal laparoscopic adrenalectomy: experience in 100 patients. J Endourol. (1997);11(5):361–365. [PubMed: 9355955]

34.

Filipponi S. et al. Laparoscopic adrenalectomy: a report on 50 operations. Eur J Endocrinol. (1998);138(5):548–553. [PubMed: 9625367]

35.

Gasman D. et al. Laparoscopic adrenalectomy: the retroperitoneal approach. J Urol. (1998);159(6):1816–1820. [PubMed: 9598466]

36.

Gill I S. et al. Needlescopic adrenalectomy-the initial series: comparison with conventional laparoscopic adrenalectomy. Urology. (1998);52(2):180–186. [PubMed: 9697779]

37.

Walz MK et al (1998) Subtotal adrenalectomy by the posterior retroperitoneoscopic approach. World J Surg 22 (6): 621–626; discussion 626–627 . [PubMed: 9597938]

38.

Smith C D, Weber C J, Amerson J R. Laparoscopic adrenalectomy: new gold standard [in process citation] World J Surg. (1999);23(4):389–396. [PubMed: 10030863]

39.

Sardi A, McKinnon W M. Laparoscopic adrenalectomy in patients with primary aldosteronism. Surg Laparosc Endosc. (1994);4(2):86–91. [PubMed: 8180773]

40.

Jacobs JK, Goldstein RE, Geer RJ (1997) Laparoscopic adrenalectomy. A new standard of care. Ann Surg 225 (5): 495–501; discussion 501–502 . [PMC free article: PMC1190783] [PubMed: 9193177]

41.

Schell S R, Talamini M A, Udelsman R. Laparoscopic adrenalectomy for nonmalignant disease: improved safety, morbidity, and cost-effectiveness [in process citation] Surg Endosc. (1999);13(1):30–34. [PubMed: 9869684]

42.

Prinz RA (1995) A comparison of laparoscopic and open adrenalectomies. Arch Surg 130 (5): 489–492; discussion 492–494 . [PubMed: 7748086]

43.

Walz M K. [Minimally invasive adrenal gland surgery] Chirurg. (1998);69(6):613–620. [PubMed: 9676363]