Laparoscopic Adrenalectomy: Norwegian Single-Center Experience of 242 Procedures
Airazat M. Kazaryan, MD,1 Irina Pavlik Marangos, MD,1 Arne R. Rosseland, MD, PHD,2 Bård I. Røsok, MD, PhD,2 Olaug Villanger, MD, PHD,2 Emir Pinjo, MD,2,* Per F. Pfeffer, MD, PHD,2 and Bjørn Edwin, MD, PhD1,2
Abstract
Background: The last 15 years have been characterized by a rapid expansion of minimally invasive surgery as treatment for adrenal diseases. During these years, both indications and surgical techniques have shown im- provements. This study analyzed an 11-year single-center experience with laparoscopic adrenalectomy.
Materials and Methods: Between January 1997 and April 2008, 242 laparoscopic adrenalectomies were per- formed in 220 patients at Rikshospitalet University Hospital. Of these, 192 patients were operated on for be- nign lesions, 23 for malignant lesions, and in 5 cases “en bloc” adrenalectomies were performed. Benign lesions included 136 hormonally active lesions (41 pheochromocytomas, 48 Conn adenomas, 25 Cushing adenomas, and 18 patients with Cushing’s disease) and 56 with hormonally inactive lesions (among them, 47 nonfunc- tional adenomas). Malignant lesions included 16 adrenal metastases and 7 adrenocortical carcinomas.
Results: All adrenalectomies were completed laparoscopically. The median time of unilatateral adrenalectomy was 85 (range, 35-325) minutes. The median blood loss was 0 (range, 0-1100) mL. There were 6 intraoperative and 7 postoperative minor complications. The number of complications did not differ between the types of adrenal pathology. Only 19% of the patients required opioids postoperatively. Per- and postoperative param- eters were homogeneous among patients with different adrenal lesions. The patients with adrenocortical car- cinoma had a distinctive intraoperative course with an evidently longer operative time and higher blood loss. The median postoperative hospital stay was 2 (range, 1-15) days. Hospital stay was the only postoperative pa- rameter where a difference was found between patients with different adrenal lesions. The patients with car- cinoma, pheochromocytoma, and Cushing’s disease had the longest median postoperative stay, respectively, 5 (range, 2-6), 3 (range, 1-15), and 3 (range, 2-6) days.
Conclusions: Laparoscopic adrenalectomy is a safe, effective procedure providing improved fast and uncom- plicated patient recovery independent of the type of adrenal lesion. Laparoscopic adrenalectomy can be easily introduced and may soon replace traditional open surgery in specialized centers.
Introduction
A DRENAL SURGERY is a fast-developing area within current medicine. Higashihara et al. and Gagner et al., in 1992, reported the first cases of laparoscopic adrenalectomy.1,2 Since that time several technical modifications have been de- scribed.3 Laparoscopic adrenalectomy has become the method of choice for the majority of adrenal lesions in a rel- atively short time. Laparoscopic equipment and operative techniques also seem to have influenced the indications for adrenalectomy during the last decade. The aim of this study
was to analyze 11-year experience of laparoscopic adrena- lectomy via a lateral transabdominal approach gained since 1997 with regards to a variety of adrenal pathologies.
Materials and Methods
Patients
Before 1997, adrenalectomies were routinely performed via laparotomy at our institution. The first laparoscopic transperitoneal adrenalectomy was performed on January 8, 1997. Since then, most adrenalectomies have been routinely
1Interventional Centre and 2Surgical Department, Rikshospitalet University Hospital, Oslo, Norway.
*Current address: Surgical Department, Diakonhjemmet Hospital, Oslo, Norway.
| Indications | Number | Age (years) | Sex (male/female) | Side (left/right/bilateral) | ASA |
|---|---|---|---|---|---|
| Benign lesions | 192 | 51 (0.5-85) | 779/113 | 91/79/22 | 2 (1-4) |
| A) Hormonally active | 136 | 49 (0.6-85) | 58/78 | 58/57/21 | 2 (2) |
| 1. Pheochromocytoma (SG 1) | 41 | 51 (13-85) | 20/21 | 21/17/3 | 3 (2-4) |
| 2. Conn adenoma (SG 2) | 48 | 48 (23-76) | 27/21 | 24/24/0 | 2 (1-4) |
| 3. Cushing adenoma (SG 3) | 25 | 45 (22-72) | 3/22 | 11/14/0 | 2 (1-3) |
| 4. Cushing's disease (SG 4) | 18 | 51.5 (13-70) | 8/11 | 2/0/16 | 2.5 (1-4) |
| 5. Other rare adrenal lesionsa | 4 | 37.5 (0.6-49) | 0/4 | 0/2/2 | 2 (1-2) |
| B) Hormonally inactive | 56 | 57 (0.5-78) | 21/35 | 33/22/1 | 2 (1-4) |
| 1. Adrenal adenoma (SG 5) | 47 | 57 (0.5-78) | 14/33 | 29/18/0 | 2 (1-4) |
| 2. Other rare adrenal lesions (SG 6)a | 9 | 63 (28-68) | 7/2 | 4/4/1 | 2 (1-3) |
| Malignant lesions | 23 | 56 (35-74) | 11/12 | 9/14 | 2 (1-4) |
| 1. Adrenocortical carcinoma (SG 7) | 7 | 37 (35-45) | 1/6 | 2/5/0 | 2 (1-4) |
| 2. Metastases in adrenals (SG 8) | 16 | 60.5 (52-74) | 10/6 | 7/9/0 | 3 (2-3) |
| "En block" resectionsb | 5 | 60 (32-74) | 1/4 | 5/0/0 | 2 (1-3) |
| P-value | <0.0001c | <0.001e | <0.001e | 0.16€ | |
| Post-hoc test: Significance of difference between SG | 3 vs. 5d | — | - | - | |
| 3 vs. 8 | |||||
| 5 vs. 7 | |||||
| 7 vs. 8 | |||||
| Total | 220 | 52 (0.5-85) | 91/129 | 105/93/22 | 2 (1-4) |
ASA, American Society of Anesthesiology; SG, statistic group.
ªSee Table 2 for details.
bAccompanied distal pancreatic resections and were performed due to invasion of pancreatic cancer in adrenal gland.
“Kruskal-Wallis test.
dDunn’s method.
eChi-squire test.
referred to the laparoscopic approach. Until April 2008, 242 laparoscopic adrenalectomies were performed in 220 pa- tients at the Rikshospitalet University Hospital (Oslo, Nor- way). Over the first 6 years, all procedures were performed or guided by one surgeon (B.E.). Later, other surgeons of the same group were trained to the procedure. Currently, three surgeons are able to perform the procedure independently (B.E., A.R., and B.R.). Clinical data were recorded retrospec- tively from 1997 to 1999, whereas subsequent data were recorded prospectively. There were 127 left-sided and 115 right-sided adrenalectomies, including 22 bilateral cases.
Of these, 192 patients were operated on for benign lesions, 23 patients for malignant lesions, and in 5 cases the adren- als were removed “en bloc” due to invasion of malignant tu- mor of the pancreas into the adrenal gland. Benign lesions included 136 patients with hormonally active lesions and 56 patients with hormonally inactive lesions. Patients’ detailed characteristics are presented in Tables 1-3.
The patient ages were in accordance with reported epi- demiologic data, the median age of which was 51 years (range, 6 months to 85 years old). Patients with adrenal car- cinoma was characterized by a relatively young age, with a median of 37 (range, 35-45) years, and the patients with adrenal metastases by a relatively higher age, with a me- dian of 60.5 (range, 52-74) years. Otherwise, the patients were relatively homogeneous in respect of age representa-
tion. The gender representation was also in accord with re- ported epidemiologic data. There was a strong female over- representation in patients with cortical carcinoma and Cushing adenoma. The American Society of Anesthesiol- ogy (ASA) index did not differ statistically in different groups.
The following intraoperative parameters were recorded: operative time, blood loss, intraoperative complications, combined procedures, blood transfusions, and need for con- version to open procedure. For statistical reasons, the im- measurably minimal blood loss was recorded as zero. Post- operatively, the following parameters were recorded: analgesic medication, postoperative complications, and the duration of postoperative hospital stay. The following groups of analgesics were used as postoperative medication: nonsteroid anti-inflammatory drugs (e.g., ketorolac, diklofenac), paracetamol, combined analgesics (dextroprox- yphene + paracetamol or codeine phosphate + paraceta- mol), and intravenous opioides (e.g., ketobemidone). The opioid administration was recorded from the first postoper- ative day. Patients with “en bloc” resections, combined pro- cedures, and a case when, after the completion of a laparo- scopic adrenalectomy, there was performed a laparotomic nephrectomy and cavatomy with tumortrombectomy were excluded from analyses of intra- and postoperative parame- ters (total, 20 cases).
| Lesions | Number |
|---|---|
| Rare benign hormonally active lesions | |
| Androgen-producing tumor | 2 |
| Andreno-genetal syndrome (bilateral | 1 |
| hyperplasia of adrenal cortex caused by 21-hydroksylase defect) | |
| McCune Albright syndrome (bilateral | 1 |
| hyperplasia of adrenal cortex) | |
| Total | 4 |
| Myelolipoma | 2 |
| Embryonic cyst | 1 |
| Pseudocyst | 1 |
| Schwannoma | 1 |
| Angioma | 1 |
| Vascular aneurysm of splenic artery | 1 |
| Accessory spleen attached to normal adrenal tissue (mimicking a tumor) | 1 |
| Bilateral hemangioma in the adrenal gland | 1 |
| Total | 9 |
Malignant lesions
| Adrenal metastases from | 16 |
| Colorectal carcinoma | 7 |
| Kidney cancer | 4 |
| Lung cancer | 3 |
| Hepatocellular carcinoma | 2 |
| Adrenocortical carcinoma | 7 |
| With Cushing's syndrome | 3 |
| With virilizing syndrome | 1 |
| Hormonally inactive | 3 |
| Total | 22 |
Surgical technique
In all cases, a transabdominal lateral laparoscopic ap- proach was used. The patient was placed in an 80-90-degree lateral position to allow gravity-facilitated exposure of the adrenal glands. In this way, tissue and organs overlying the adrenal glands do not need to be manipulated with laparo- scopic instruments, and the complications associated with such manipulation can be avoided.
The surgeon and the assistant were positioned on the ab- dominal side. Two monitors were placed on each side of the head of the operating table. Using an open technique (skin incision 11-12 mm, splitting fascia and muscle layers, and careful dissection and perforation of the peritoneum) a 30- degree laparoscope inside a 12-mm trocar was inserted just lateral of the pararectal line, a few centimeters above the um- bilicus. Then, carbon dioxide (CO2) was insufflated through the trocar with a pressure of 8-10 mm Hg. For the additional ports (two on the left side and three on the right side), 12- mm trocars were used and placed in a way that created a nearly curve-shaped line against the target under the costal
margin. On the right side, we inserted a fourth trocar just below the costal margin in the pararectal or medial line.
The dissection on the left side was started by releasing the left colon flexure, if necessary. Then, the spleen and the pan- creatic tail were dissected free from the posterior wall up to the stomach and mobilized anteriorly. In most cases, the adrenal vein was dissected free and divided between clips be- fore the adrenal gland was dissected free itself. Dissection was facilitated by using an ultrasound dissector, the AutoSonix (AutoSuture, Norwalk, CT) and, in a few cases, the Ultra- cision (Ethicon, Cincinnati, OH). With these methods, the adrenal gland was dissected free without having to clip the adrenal arteries. From 2007, the LigaSure (Tyco/Covidien, Boulder, CO) bipolar electrocoagulator was used, enabling the coagulation of even larger vessels, such as the adrenal vein. The dissected specimen was placed into an Endo-Catch (AutoSuture) and retracted through the primary incision.
On the right side, the dissection started with the mobi- lization of the right liver lobe from the caval vein and the right diaphragm, which then fell anteriorly. Careful dissec- tion was then done, starting at the caudal part of the adrenal gland along the lateral aspect of the inferior caval vein in the cranial direction to identify the right adrenal vein. The vein was dissected free and divided between clips. The rest of the procedure was as described for the left side. In a few cases, the surgery was performed with one surgeon assisted by the robot AESOP (ComputerMotion, Galeta, CA).
Statistics
Statistical data are presented as the median (range) and mean ± standard error. For comparison of frequencies, the chi-square test was performed. For analysis of continuous variables, the Kruskal-Wallis test was used. The post-hoc Dunn’s method was applied to find the differences between
| Procedures | Number |
|---|---|
| Distal pancreatic resection due to Pseudocyst in pancreatic tale Gastrinoma (procedure was accompanied with lymphadenenectomy) Endocrine tumor in pancreas Adrenal metastasis growing in pancreas tail | 4 |
| Cholecystectomy | 1 |
| Liver resection (due to colorectal metastasis) | 1 |
| Right hemicolectomy (adenocarcinoma of the colon ascendens) | 1 |
| Bilateral removal of intra-abdominal testicles | 1 |
| Bariatric stomach surgery | 1 |
| Resection of accessory spleen | 1 |
| Resection of renal cyst (due to renal carcinoma) | 1 |
| Umbilical hernia repair | 1 |
| Removal of paraganglion from the area of kidney hilus | 1 |
| Free dissection of pancreatic tail (chronic pancreatitis, chronic abdominal pain) | 1 |
| Total | 14 |
| Indications | Operative time (min) | Blood loss (mL) | Blood transfusion | Intraoperative complications | Tumor size (cm) | |
|---|---|---|---|---|---|---|
| Median (range) | Median (range) | Mean standard error | Intra-/ postoperative | Median (range) | ||
| Benign lesions | 99 (35-325) | 0 (0-1000) | 66 ± 14 | 0/1 | 4 | 3.3 (0.5-11) |
| A) Hormonally active | 100 (35-325) | 0 (0-1000) | 81 ± 19 | 0/1 | 4 | 3 (0.6-11) |
| 1. Pheochromocytoma (SG 1) | ||||||
| All | 102 (45-240) | 0 (0-1000) | 158 ± 47 | 0/1 | 2 | 4.5 (1-11) |
| Only unilateral cases | 95 (45-235) | 0 (0-1000) | 157 ± 51 | |||
| 2. Conn adenoma (SG 2) | 80 (35-160) | 0 (0-150) | 22 ± 6 | 0 | 2 | 1.8 (0.6-3.2) |
| 3. Cushing adenoma (SG 3) | 90 (45-325) | 0 (0-400) | 33 ± 18 | 0 | 0 | 3.8 (2-6.5) |
| 4. Cushing disease (SG 4) | ||||||
| All | 167 (70-275) | 20 (0-600) | 109 ± 52 | 0 | 0 | - |
| Only bilateral cases | 170 (125-275) | 35 (0-600) | 114 ± 51 | |||
| 5. Other lesions | 85 (45-125) | 0 (0-50) | 13 ±13 | 0 | 0 | — |
| B) Hormonally inactive | 71 (38-110) | 0 (0-400) | 22 ± 66 | 0 | 0 | 3.9 (0.5-9.5) |
| 1. Adrenal adenoma (SG 5) | 70 (38-110) | 0 (0-500) | 32 ± 15 | 0 | 0 | 3.5 (0.5-7.5) |
| 2. Other lesions (SG 6) | 95 (65-110) | 0 (0-90) | 24 ± 14 | 0 | 0 | 5.5 (3-9.5) |
| Malignant lesions | 124 (50-195) | 100 (0-1100) | 175 ± 58 | 1/1 | 2 | 8 (2-16) |
| 1. Adrenocortical | 157 (114-195) | 250 (50-1100) | 350 ±160 | 0/1 | 1 | 10 (5.2-13) |
| carcinoma (SG 7) | ||||||
| 2. Metastases in adrenals | 120 (50-315) | 50 (0-5000) | 100 ± 37 | 1/0 | 1 | 7 (2-16) |
| (SG 8) | ||||||
| P value | <0.0001ª | <0.0001ª | 0.06℃ | 0.35€ | <0.0001ª | |
| Post-hoc test: Significance | 1 vs. 2b | 1 vs. | 5b | — | — | 1 vs. 2b |
| of difference between SG | 1 vs. 4 | 2 vs. | 7 | 1 vs. 5 | ||
| 1 vs. 5 | 3 vs. | 7 | 1 vs. 7 | |||
| 1 vs. 7 | 5 vs. | 7 | 2 vs. 3 | |||
| 2 vs. 4 | 6 vs. | 7 | 2 vs. 5 | |||
| 2 vs. 7 | 7 vs. | 8 | 2 vs. 6 | |||
| 3 vs. 4 | 2 vs. 7 | |||||
| 3 vs. 5 | 2 vs. 8 | |||||
| 3 vs. 7 | 3 vs. 7 | |||||
| 4 vs. 5 | 3 vs. 8 | |||||
| 4 vs. 6 | 5 vs. 6 | |||||
| 4 vs. 8 | 5 vs. 7 | |||||
| 5 vs. 7 | 5 vs. 8 | |||||
| 6 vs. 7 | 6 vs. 7 | |||||
| 5 vs. 7 | ||||||
| 7 vs. 8 | ||||||
| Total | 95 (35-325) | 0 (0-1100) | 79 ± 14 | 1/2 | 6 | 3.5 (0.5-13) |
| Total unilateral | 85 (35-325) | 0 (0-1100) | 71 ± 14 | 1/2 | 6 | 3.5 (0.5-13) |
| Total bilateral | 170 (125-275) | 50 (0-600) | 118 ±36 | 0 | 0 | 3 (3-7) |
SG, statistic group.
ªKruskal-Wallis test.
bDunn’s Method.
“Chi squire test.
groups. The statistical comparisons were performed between eight statistical groups representing major adrenal lesion types, excluding only cases of very rare hormonally active adrenal lesions (3 patients) and “en bloc” resections (5 pa- tients) (Tables 1 and 2). Further, the patients with unilateral adrenalectomies were divided into three groups, based upon in which period of time they were operated on, either the initial (before 2001), intermediate (2002-2005), or late period (since 2006), in order to compare major intraoperative pa- rameters. The Kaplan-Meier method was applied for sur- vival analyses. The mean follow-up of patients with adreno-
cortical carcinoma and with metastases in the adrenal gland was 22 ± 8 and 31 ± 4 months, respectively. The study was approved by the Hospital Review Board and the Regional Ethics Committee in Medicine and Healthcare.
Results
Operative data
All adrenalectomies were successfully completed by the laparoscopic approach (Tables 4 and 5). The median opera- tive time was 85 (range, 35-325) minutes for the unilateral
| Indications | Tumor size (cm) | Operative time (min) | Blood loss (mL) | Blood transfusion | Intraoperative complications | |
|---|---|---|---|---|---|---|
| Median (range) | Median (range) | Median (range) | Mean ± standard error | |||
| Initial period | 3.1 (0.8-11) | 100 (35-325) | 50 (0-500) | 82 ± 16 | 1 | 2 |
| 1997-2001 (group A) (N = 54) | ||||||
| Intermediate period 2002-2005 | 3.8 (0.5-16) | 77 (38-230) | 0 (0-1100) | 86 ± 22 | 2 | 3 |
| (group B) (N = 69) | ||||||
| Last period post-2006 (group C) (N = 55) | 3.5 (0.6-13) | 82 (45-170) | 0 (0-200) | 31 ± 9 | 0 | 1 |
| P-value | 0.6ª | 0.03ª | 0.04ª | 0.46℃ | 0.73c | |
| Post-hoc test: | — | A vs. Bb | A | vs. Cb | — | — |
| Significance of difference between groups | A vs. C | B vs. | C | |||
ªKruskal-Wallis test.
bDunn’s Method.
“Chi-square test.
and 170 (range, 125-275) minutes for bilateral adrenalec- tomy. The patients had a statistically significant difference in operative time in the case of diverse adrenal lesions. The median operative time of unilateral cases was 95 (range, 45-235) minutes for patients with pheochromocytoma, 80 (range, 35-160) minutes for patients with Conn adenoma, 90 (range, 45-325) minutes for patients with Cushing adenoma, 70 (range, 38-110) minutes for patients with nonfunctional cortical adenoma, 112 (range, 50-175) minutes for patients with metastatic lesions, and 157 (range, 114-195) minutes for patients with adrenocortical carcinoma. The median opera- tive time for patients with Cushing’s disease (mainly bilat- eral cases) was 167 (range, 70-275) minutes.
The median blood loss was 0 (range, 0-1100) mL for the unilateral and 50 (range, 0-600) mL for bilateral adrenalec- tomy. The patients were quite homogeneous with respect to blood loss. Only patients operated on for adrenocortical car- cinoma with a median blood loss of 250 (range, 50-1100) mL had a statistically higher blood loss than all other groups, ex- cept those operated on for pheochromocytoma and Chus- ing’s disease. Besides, the patients with pheochromocytoma had a statistically higher blood loss than those who were op- erated on for nonfunctional cortical adenoma.
Three patients required a blood transfusion (intraopera- tively 1, postoperatively 2). A total of 6 intraoperative com- plications were registered. Of these, 2 happened in the pheochromocytoma group: bleeding from an aneurism of the splenic artery (clipping, 1000-mL blood loss, instable hemo- dynamics, and postoperative blood transfusion) and a splenic vein injury (clipping, 1000-mL blood loss). Two com- plications were seen in the Conn group: a minor rupture of the liver capsule (suturing) and a small hole in the di- aphragm (suturing). There were recorded 1 complication in
the metastasis group and 1 in the carcinoma group, a minor hole in the small bowel (suturing), and a minor rupture of the tumor capsule (suturing), respectively. After successful laparoscopic adrenalectomy in the patient with cortical car- cinoma, the procedure was converted to open surgery to per- form cavatomy and trombectomy due to a tumor thrombus in the inferior caval vein discovered by laparoscopic ultra- sonography. The comparison of major intraoperative pa- rameters of our initial, intermediate, and late experience found only slight significant differences in operative time and blood loss.
Histology
The median tumor size was 3.5 (range, 0.7-13) cm (Table 4). Patients had a statistically significant difference in tumor size in the case of different adrenal lesions. The median size was 4.5 (range, 1-11) cm for patients with pheochromocy- toma, 1.8 (range, 0.6-3.2) cm for patients with Conn ade- noma, 3.8 (range, 2-6.5) cm for patients with Chushing adenoma, 3.5 (range, 0.5-7.5) cm for patients with nonfunc- tional cortical adenoma, 7 (range, 2-16) cm for patients with metastatic lesions, and 10 (range, 5.2-13) cm for patients with adrenocortical carcinoma.
Postoperative parameters
A large majority of the patients in all categories started to drink and eat at the day of operation in all groups of patients (Table 6). Only 34 patients required opioid administration on the fist postoperative day; of those, 6 patients also re- ceived opioids on the second postoperative day and just 1 patient required opioid medication longer than 2 days (un- til the fourth postoperative day). The median postoperative
| Indications | A postoperative day of intake of fluids (day) | A postoperative day of intake of solid feeding (day) | Patient received opioids postoperatively | Postoperative complications | Postoperative hospital stay (days) |
|---|---|---|---|---|---|
| Benign lesions | 0 | 0 (0-2) | 30 | 6 | 2 (1-15) |
| A) Hormonally active | 0 (0-1) | 0 (0-2) | 21 | 6 | 2 (1-15) |
| 1. Pheochromocytoma | 0 (0-1) | 0 (0-1) | 5 | 2 | 3 (1-15) |
| (SG 1) | |||||
| 2. Conn adenoma (SG 2) | 0 | 0 (0-2) | 8 | 3 | 2 (1-6) |
| 3. Chushing adenoma (SG 3) | 0 | 0 (0-1) | 4 | 1 | 2 (1-5) |
| 4. Chushing's disease (SG 4) | 0 | 0 (0-1) | 4 | 0 | 3 (2-6) |
| 5. Other lesions | 0 | 0 | 0 | 0 | 1.5 (1-2) |
| B) Hormonally inactive | 0 | 0 (0-1) | 9 | 0 | 2 (1-6) |
| 1. Adrenal adenoma | 0 | 0 (0-1) | 7 | 0 | 2 (1-6) |
| (SG 5) | |||||
| 2. Other lesions | 0 | 0 (0-1) | 2 | 0 | 2 (2-4) |
| (SG 6) | |||||
| Malignant lesions | 0 (0-1) | 0 (0-1) | 4 | 1 | 2 (1-6) |
| 1. Adrenocortical | 0 (0-1) | 0 (0-1) | 2 | 0 | 5 (2-6) |
| carcinoma (SG 7) | |||||
| 2. Metastases in | 0 (0-1) | 0.5 (0-1) | 2 | 1 | 2 (1-5) |
| adrenals (SG 8) | |||||
| P-value | 0.3ª | 0.4ª | 0.95b | 0.68b | <0.0001b |
| Post-hoc test: | — | — | — | — | 1 vs. 5 |
| Significance of | 2 vs. 7 | ||||
| difference | 3 vs. 7 | ||||
| between SG | 4 vs. 5 | ||||
| 5 vs. 7 | |||||
| 7 vs. 8 | |||||
| Total | 0 (0-1) | 0 (0-2) | 34 | 7 | 2 (1-15) |
SG, statistic group.
ªKruskal-Wallis test.
bChi squire test.
hospital stay was 2 (range, 1-15) days. Only patients oper- ated on for adrenocortical carcinoma with the median post- operative hospital stay of 5 (range, 2-6) days had a statisti- cally longer postoperative hospital stay than all the other groups, except pheochromocytoma and Cushing’s disease. Besides, the patients with pheochromocytoma had a statis- tically longer postoperative hospital stay-3 (range, 1-15) days-than those who were operated on for nonfunctional cortical adenoma-2 (range, 1-5) days.
There was 1 case of postoperative mortality, as a 71-year- old patient with Cushing’s disease died on the third post- operative day from cardiopulmonary failure. The patient was critically ill preoperatively with uncontrollable levels of cortisol, severe hypertension, and chronic renal insuffi- ciency. The surgery was urgent and was conducted as an at- tempt to save his life. There were registered 7 postoperative complications: 3 in the Conn group (pneumonia, subcuta- neous emphysema, and urine infection), 2 in the pheochro- mocytoma group (right-sided spontaneous pneumothorax, drainage; bronchopneumonia), 1 in the Cushing adenoma group (subcapsular liver hematoma), and 1 in the group with metastases (small retroperitoneal hematoma, treated med- ically). The 2-year actuarial survival of patients with adreno- cortical carcinoma and with metastases in the adrenal gland
were 41 and 42, with the mean survival being 26 ± 9 and 35 ± 5 months, respectively.
Discussion
The benefits of laparoscopic adrenalectomy over open sur- gery for benign lesions, either hormonally active or inactive, are now broadly accepted.4-9 The results are such that ran- domized trials comparing the two techniques are currently considered nonethical, and it is, therefore, doubtful that such a study will ever be conducted.10 The introduction of the laparoscopic transperitoneal adrenalectomy has greatly changed the management of adrenal pathology at our insti- tution as well. However, in spite of general acceptance, the laparoscopic adrenalectomy is still considered controversial for some indications. First of all, this is related to patients with malignant lesions. An operation for these indications must be performed with caution to avoid tumor fragmenta- tion, and standard oncologic principles have to be main- tained.11,12
Since 1997, only four open adrenalectomies have been per- formed at our institution, all for adrenocortical carcinomas. Thus, during this time frame, only 4 of 11 adrenocortical car- cinomas and none of the metastases in the adrenal gland
LAPAROSCOPIC ADRENALECTOMY
have been referred to open adrenalectomy. The reason for laparotomy in these 4 patients was very large tumor size, deeply invasive growth into neighboring organs, and major vessels requiring concomitant resections.
Laparoscopic adrenalectomy for carcinoma is associated with substantially increased technical demands for even the well-experienced laparoscopic surgeon; in our series, it re- sulted in a significant increase of operative time and blood loss. Although the adrenalectomy for metastatic lesions pre- sented a certain degree of technical challenge for the sur- geon, intraoperative parameters however, of those patients did not significantly differ from the patients operated on for unilateral benign adrenal lesions, as also supported by pre- vious reports.13,14 In spite of promising early oncologic out- comes, further studies are required to define whether lapa- roscopic resection provides late oncologic outcomes similar to open resection.11-15
A large tumor size itself was not considered to be a con- traindication for the laparoscopic adrenalectomy. In our se- ries, 42 patients had a tumor size of 6 cm or larger, 24 pa- tients were with tumors ≥8 cm, and 10 with ≥10 cm. However, we did not experience major technical difficulties operating on the majority of those patients. As our early study shows, the tumor size was associated with slightly in- creased operative time and blood loss due to extended vol- ume of dissection, but not with a higher complication rate.15-18
The transabdominal approach was used in all cases. Some surgeons prefer the retroperitoneal approach, but that method does not have clear advantages over transperitoneal access.3,19 We believe that both methods provide quite sim- ilar and good outcomes, and that the choice is dependant on personal preference. Nevertheless, transperitoneal laparo- scopic access is more universal, as it may be applied in the vast majority of adrenalectomy cases, while tumor size is a limitation for the retroperitoneal approach.19 Besides this, transabdominal laparoscopy enables the surgeon to perform a complete assessment of the abdominal cavity that is an im- portant factor in the case of malignant disease.
It is impossible to make a comprehensive conclusion with regard to the applicability of the medical robot, AESOP. It could possibly find its place in hospitals, where there is a se- vere shortage of surgeons.20-22 We did not feel a significant advantage of its application; therefore, the medical robot AESOP was not used in many cases.
Thirty-nine patients had had previous open abdominal surgery without this being a contraindication to laparoscopic adrenalectomy.23,24 All these patients underwent a success- ful laparoscopic adrenalectomy. No statistical differences were found in any per- or postoperative parameters. The in- traoperative parameters for benign unilateral lesions were quite homogeneous. The most unilateral adrenalectomies were performed within 70-100 minutes with minimal blood loss. Only 6 patients had blood loss higher than 500 mL. There were 4 patients with pheochromocytoma, 1 patient with adrenocortical carcinoma, and 1 with Cushing disease. There was bleeding from a splenic artery aneurism in 1 case, bleeding from the splenic vein in 1 other case, and diffuse bleeding from the resection line in 4 other cases. Our results differ from early reports of other researchers reporting ma- jor differences in intraoperative parameters due to type of adrenal lesions.25,26 Our explanation is that the essential lap-
aroscopic experience and modern laparoscopic equipment have enabled us to achieve good intraperative parameters for traditionally challenging indications, such as as pheochromocytoma and Cushing’s syndrome. We noticed that in our early experience, the laparoscopic adrenalectomy on the left side was more time consuming due to some dif- ficulties with dissection in the correct layer between the pan- creatic tail, the spleen, and the adrenal gland. However, with improved experience, no statistical differences were found in operative time between left- and right-sided procedures, as also shown by other researchers.27,28
The postoperative parameters of all patients were also quite homogeneous. The vast majority of patients started to drink and eat on the day of the operation, and the median postoperative hospital stay was 2 days. This was achieved by a close collaboration of surgeons, anesthesiologists, and an endocrinologist. Only patients with adrenocortical carci- noma, pheochromocytoma, and Cushing’s disease had a longer postoperative hospital stay, with a median of 5, 3, and 3 days, respectively. The latter two groups required addi- tional time due to control of hormonal status and safe es- tablishment of hormone substitutive therapy. Regarding Conn adenoma and low-risk incidentalomas, we are of the opinion that most of these patients may receive day surgery with laparoscopy.29,30 It is feasible and safe and yields ex- cellent patient satisfaction. The necessary surgical experience and optimal anesthesia are of crucial importance in this con- text.
We had 22 patients with bilateral adrenalectomy, includ- ing 16 with Cushing’s disease, 3 with bilateral pheochromo- cytoma, 1 with adrenogenital syndrome, 1 with McCune Al- bright syndrome, and 1 bilateral hemangioma. In the case of Cushing’s disease (pituitary tumor, bilateral hyperplasia of adrenal cortex), we performed a complete adrenalectomy in all cases. In patients with bilateral pheochromocytoma, we performed an adrenal-sparing procedure in 1 of 3 our pa- tients, as it was suggested by some researchers.31,32 In gen- eral, our patients with bilateral adrenalectomy had a smooth intra- and postoperative course and were discharged on the third postoperative day.33-35
The introduction of laparoscopic adrenalectomy extended the indications for adrenalectomy as a procedure.36,37 It en- ables surgical treatment for patients with very poor somatic status, who previously were refused surgical treatment. Modern visualization technologies, such as magnetic reso- nance imaging and computed tomography, have provided a significantly higher detection of adrenal glands with so- called incidentalomas. Laparoscopic surgery could have in- creased the amount of adrenalectomies in this group. This may also become a valuable contribution to the early treat- ment of adrenal cancer. The comparison of surgical outcomes over time revealed that it is possible to achieve a very good clinical outcome after a relatively small number of proce- dures within a relatively short time. However, a wide expe- rience in laparoscopic surgery and a utility of the best ad- junct endoscopic instruments are prerequisites.
Conclusions
Laparoscopic adrenalectomy is a safe, effective procedure independently to the type of adrenal lesions. The method provides a fast-track surgery concept, few complications,
easy patient recovery, and a short hospital stay. However, the procedure requires advanced laparoscopic skills. The team work of surgeons, anesthesiologists, the endocrinolo- gist, and oncologists is of crucial importance. We believe that the laparoscopic adrenalectomy can easily be introduced and may soon replace traditional open surgery in specialized cen- ters.
Disclosure Statement
No competing financial interests exist.
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Address reprint requests to: Airazat M. Kazaryan, MD Interventional Centre Rikshospitalet University Hospital Sognsvannsveien 20 0027, Oslo Norway
E-mail: airazat.kazaryan@rikshospitalet.no kazaryan@gmail.com