Laparoscopic partial or cortical-sparing adrenalectomy by dividing the adrenal central vein

Impact of indocyanine green on decision making for performing laparoscopic cortical sparing adrenalectomy

BACKGROUND

Indocyanine green imaging (ICG) is an expansion technology that can contribute to the development of demanding techniques such as cortical-sparing adrenalectomy (CSA). The aim of this study was to determine in which cases CSA should be performed and when total adrenalectomy should be performed instead based on ICG fluorescence. Here, we present our experience through a series of cases and videos.

METHODS

Prospective and descriptive study on patients with surgical adrenal lesions who were proposed for CSA using ICG with near-infrared fluorescence imaging in our center. A first bolus of 6,25 mg ICG was administered intravenously upon exposure of the retroperitoneal plane. Fluorescence was visualized using a Storz® NIR/ICG endoscopic system.

RESULTS

Seven patients were proposed for CSA. After the application of ICG, a change in attitude was carried out in 71.4% of the cases (five of seven). In the two patients in whom CSA could be performed, the adrenal remnants were functional, and the resection margins of the surgical specimens were free of disease. The reasons why partial adrenalectomy could not be completed, and a total adrenalectomy was decided instead were the presence of a tumor located very close to the adrenal vein that prevented a correct remnant volume (n = 4) and one case of isofluorescent tumor with the adrenal parenchyma.

CONCLUSION

ICG fluorescence guidance could help in the decision making to select patients intraoperatively for successful cortical preservation.

Total adrenalectomy versus subtotal adrenalectomy for bilateral pheochromocytoma: meta-analysis

BACKGROUND

Bilateral pheochromocytomas are rare and often heritable. Total adrenalectomy leads to a definitive oncological cure, with subsequent definitive hypocortisolism. Subtotal adrenalectomy is a possible alternative. The aim of this study was to assess the effects of total adrenalectomy and subtotal adrenalectomy on bilateral pheochromocytoma in terms of post-surgical rate of recurrence, metastatic disease, and steroid dependence.

METHODS

Systematic searches in the bibliographic databases PubMed, Embase, and Europe PMC were performed for 1945 to 1 June 2023. PRISMA guidelines were followed and the PICO strategy was applied to English-language studies comparing subtotal adrenalectomy with total adrenalectomy. A random-effects model was used to assess the different outcomes for studies with high heterogeneity. The Newcastle-Ottawa scale and the Risk Of Bias In Non-randomized Studies of Interventions ('ROBINS-I') tool were used to assess quality and risk of bias.

RESULTS

From a total of 12 909 studies, 1202 patients (from 10 retrospective studies) were eligible for the meta-analysis. In six studies, including 1176 patients, the recurrence rate after subtotal adrenalectomy and total adrenalectomy was 14.1 versus 2.6 per cent respectively (OR 4.91, 95 per cent c.i. 1.30 to 18.54; P = 0.020; I2 72 per cent). In nine studies, including 1124 patients, the rate of post-surgical steroid dependence was 93.3 versus 11.6 per cent after total adrenalectomy and subtotal adrenalectomy respectively (OR 0.003, 95 per cent c.i. 0.0003 to 0.03; P < 0.00001; I2 66 per cent). Based on two studies, including 719 patients, no differences were evident regarding the occurrence of post-surgery metastatic disease.

CONCLUSION

Subtotal adrenalectomy leads to less post-surgical primary adrenal insufficiency, but leads to a higher postoperative recurrence rate. Future prospective randomized studies, with clear eligibility criteria, are needed to confirm these results.

Surgical approaches to the adrenal gland

PURPOSE OF REVIEW

Review the literature on the surgical management of adrenal diseases, highlighting the various surgical approaches and their respective pros and cons.

RECENT FINDINGS

Minimally invasive adrenalectomy is commonly used for small and benign adrenal tumors, whereas open adrenalectomy is preferred for larger tumors and primary adrenal malignancy. Although minimally invasive adrenalectomy results in shorter recovery and fewer complications compared with open, the latter offers better oncologic outcomes in the setting of primary adrenal malignancy. Adrenalectomy is performed transabdominally or retroperitoneoscopically, both yielding equivalent results and recovery. Traditional laparoscopic or robotic equipment can be utilized for either minimally invasive approach. Subtotal adrenalectomy may be appropriate for patients with genetically associated pheochromocytoma to preserve cortical function and reduce the risk of adrenal insufficiency. However, the potential benefits of sparing adrenal function must be weighed against the risk of recurrence.

SUMMARY

Adrenalectomy is becoming increasingly common worldwide. For benign and small adrenal tumors, minimally invasive adrenalectomy is generally considered the standard approach, while open adrenalectomy is preferred for primary adrenal malignancy and larger tumors. Subtotal adrenalectomy may be appropriate for patients with bilateral adrenal pheochromocytoma, as it can reduce the need for lifelong glucocorticoid dependency.

Simultaneous bilateral laparoscopic cortical-sparing adrenalectomy for bilateral pheochromocytomas in multiple endocrine neoplasia type 2

Purpose

This study aimed to assess the feasibility of synchronous bilateral laparoscopic or open cortical-sparing adrenalectomy (SB-LCSA or SB-OCSA) for bilateral pheochromocytomas (bPHEOs) in multiple endocrine neoplasia type 2 (MEN2).

Methods

Altogether, 31 patients (54.8% were women) were diagnosed with MEN2-related bPHEOs, and 29 of them underwent varying specific adrenalectomies. We systematically analyzed and evaluated their clinical profiles, mutation types, tumor histopathological features, and follow-up records.

Results

All 31 patients with bPHEOs presented with RET-C634 (90.3%) and RET-M918T (9.7%) mutations, and the median age at initial presentation was 38 years (range, 23-78). bPHEOs were synchronous in 27 patients and metachronous in 4 (12.9%) patients. In total, 29 patients underwent initial cortical-sparing adrenalectomy (CSA) including 23 (79.3%) undergoing synchronous bilateral CSA (18 SB-LCSA and 5 SB-OCSA) and 6 (20.7%) undergoing metachronous CSA. SB-LCSA and synchronous surgery were associated with less bleeding volume and shorter length of hospital stay than SB-OCSA and metachronous surgery (all P's < 0.05). Corticosteroid replacement treatment was necessary for 14 patients (45.2%) after bilateral CSA. During a median follow-up period of 7 years (range, 1.8-23), three of these patients (10.3%) had a recurrent disease that required reoperation.

Conclusion

SB-LCSA is feasible for treating synchronous bPHEOs and should be recommended as a prioritized surgical approach.

Long-term Functional and Oncologic Outcomes of Partial Adrenalectomy for Pheochromocytoma

OBJECTIVE

To evaluate the recurrence and functional outcomes in a primarily hereditary cohort of patients undergoing partial adrenalectomy for pheochromocytoma.

METHODS

A retrospective review from a prospectively managed database of patients undergoing partial adrenalectomy from 1995 to 2018 at the National Cancer Institute was performed. Local recurrence was defined as imaging evidence of a recurrent or de novo lesion on the operative side. Steroid dependency was defined as requiring daily steroid replacement at time of last follow-up.

RESULTS

One hundred and twenty-four partial adrenalectomies, removing 162 tumors, were performed in 107 patients. Most patients had a known hereditary predisposition to develop bilateral, multifocal, and recurrent pheochromocytoma. Median tumor size was 2 cm (interquartile range (IQR) 1.5-2.8). Median follow-up was 60 months (IQR 13-131). Local recurrence occurred in 17 patients (15.8%) and were managed with active surveillance or surgery. A single patient (1/106, 0.9%) developed metastatic spread of pheochromocytoma approximately 14 years after his first of 2 partial adrenalectomies and remains alive under active surveillance. Median time to recurrence was 71 months (IQR 26-127) with 10 patients (9.3%) requiring daily steroid replacement at time of last follow-up.

CONCLUSION

Partial adrenalectomy offers excellent oncologic and functional outcomes, sparing most patients from lifelong steroid replacement therapy. Recurrences can be easily managed with repeat surgery or active surveillance via functional work-up and imaging. Partial adrenalectomy remains the recommended surgical management for patients pre-disposed to development of bilateral, multifocal and recurrent pheochromocytoma.

Adrenalectomy for Cushing's syndrome: do's and don'ts

Aim. To present specific aspects of adrenalectomy for Cushing’s syndrome (CS) by introducing well established aspects (“do’s”) and less known aspects (“don’ts”).

Material and Method. This is a narrative review.

Results. The “do’s” for laparoscopic adrenalectomy (LA) are the following: it represents the “gold standard” for secretor and non-secretor adrenal tumors and the first line therapy for CS with an improvement of cardio-metabolic co-morbidities; the success rate depending on the adequate patients’ selection and the surgeon’s skills. The “don’ts” are large (>6-8 centimeters), locally invasive, malignant tumors requiring open adrenalectomy (OA). Robotic adrenalectomy is a new alternative for LA, with similar safety and conversion rate and lower pain drugs use. The “don’ts” are the following: lack of randomized controlled studies including oncologic outcome, different availability at surgical centers. Related to the sub-types of CS, the “do’s” are the following: adrenal adenomas which are cured by LA, while adrenocortical carcinoma (ACC) requires adrenalectomy as first line therapy and adjuvant mitotane therapy; synchronous bilateral adrenalectomy (SBA) is useful for Cushing’s disease (only cases refractory to pituitary targeted therapy), for ectopic Cushing’s syndrome (cases with unknown or inoperable primary site), and for bilateral cortisol producing adenomas. The less established aspects are the following: criteria of skilled surgeon to approach ACC; the timing of surgery in subclinical CS; the need for adrenal vein catheterization (which is not available in many centers) to avoid unnecessary SBA.

Conclusion. Adrenalectomy for CS is a dynamic domain; LA overstepped the former OA area. The future will improve the knowledge related to RA while the cutting edge is represented by a specific frame of intervention in SCS, children and pregnant women.

Abbreviations: ACC = adrenocortical carcinoma, ACTH = Adrenocorticotropic Hormone, CD = Cushing’s disease, CS = Cushing’s syndrome, ECS = Ectopic Cushing’s syndrome, LA = laparoscopic adrenalectomy, OA = open adrenalectomy, PA = partial adrenalectomy, RA = robotic adrenalectomy, SCS = subclinical Cushing’ syndrome

Right lateral decubitus approach to a laparoscopic modified Hassab's operation

INTRODUCTION

The lateral approach is the standard for laparoscopic splenectomy. However, when the modified Hassab's operation is performed laparoscopically, the patient is placed in the supine position and then the right semi-lateral or lateral decubitus position. Based on our experience with laparoscopic adrenalectomy and splenectomy, we laparoscopically performed the modified Hassab's operation with the patient in the right lateral decubitus position.

MATERIALS AND SURGICAL TECHNIQUE

Indications for the modified Hassab's operation for patients with portal hypertension in our institute include both gastric varices and hypersplenism resistant to endoscopic or radiologic procedures. We performed splenectomy and devascularization of the greater curvature and then dissected adhesions between the stomach, pancreas, and gastrohepatic ligament. With the patient in the right lateral decubitus position, the lesser curvature could be identified from both the ventral and dorsal sides.

DISCUSSION

For the modified Hassab's operation, as in laparoscopic gastrectomy, many operators select the supine position for lesser curvature devascularization and gastric vessel ligation. However, after sufficient adhesion dissection around the stomach, anatomical structures can be identified in the right lateral decubitus position. For this approach, gravity is not an issue on the dorsal side, and the lesser curvature can be observed from both the ventral and dorsal sides with the patient in the right lateral decubitus position. Laparoscopically performing the modified Hassab's operation with the patient in the right lateral decubitus position is a feasible method.

Cortex sparing laparoscopic adrenalectomy in a patient with Conn's syndrome

Conn's syndrome, an aldosterone producing adenoma, is a surgically curable cause of primary aldosteronism, classically treated by unilateral adrenalectomy. With the advent of laparoscopic surgery in the recent decade, laparoscopic adrenalectomy is currently accepted as the gold standard of treatment for Conn's syndrome. Cortical sparing adrenalectomy is especially an ideal operation for patients with bilateral pheochromocytoma. This case report describes a successful laparoscopic adrenal cortex sparing surgery on the left side and anesthetic approach in a patient with Conn's syndrome, who had a history of previous right surrenalectomy. Laparoscopic surgery without dividing the central adrenal vein can also be performed successfully in patients with Conn's syndrome.

[Partial laparoscopic adrenalectomy in primary hyperaldosteronism]

INTRODUCTION

primary hyperaldosteronism is one of the few potentially curable causes of secondary arterial hypertension. One of the most important variants is the adenoma of the adrenal cortex that produces aldosterona (Conn's Syndrome). The treatment of choice in this subgroup of patients was the removal of the lesion. An initial series of patients with aldosteronoma subjected to partial laparoscopic adrenalectomy is presented.

MATERIALS AND METHOD

We examined the case selection and methods applied to hypertensive patients subjected to partial laparoscopic adrenalectomy between November 2001 and March 2004 due to primary hyperaldosteronism. They all presented an imaging study (CT scan) compatible with a tumour of the adrenal cortex and, in two patients the lesion was bilateral. One patient had a history of incidental adrenalectomy during and open colecistectomy performed some years previously.

RESULTS

we operated on 16 patients, 13 of them women and 3 men, with a mean age of 55.4 years. We performed 18 laparoscopic adrenalectomies: 17 conservative operations and one total adrenalectomy of a 4.3 cm tumour in a patient with bilateral lesion. The mean duration of the operations was 70.9 minutes, with a mean bleeding rate of 30 ml. There were no complications or the need to resort to open surgery. Postoperative hospital stay was 2.8 days. In all the cases, the hypertension improved totally or partially.

CONCLUSION

although small, the series confirmed that partial laparoscopic suprarenalectomy can be performed with good results and with the advantages of minimally invasive surgery.

Importance of the adrenal gland blood supply during laparoscopic subtotal adrenalectomy

INTRODUCTION

Laparoscopic subtotal adrenalectomy (LSA) has emerged as a treatment option in the management of certain adrenal pathologies. After LSA, a satisfactory blood supply to the adrenal remnant is vital to preserve steroid function. The aim of this study was to review the adrenal blood supply with relevance to LSA.

MATERIALS AND METHODS

The adrenal blood supply was examined in three ways: 1) a review of six previous cadaver studies looking at adrenal blood supply; 2) a review of our 164 consecutive laparoscopic adrenalectomies (LAs) (January 1999-January 2009); the details of the main adrenal veins and variants had been prospectively recorded; and 3) dissection of 4 cadaver specimens (macroscopic and histologic examination was performed).

RESULTS

The six cadaver studies showed duplication or triplication of the main adrenal vein with variable frequency. Four of six studies described smaller peripheral veins surrounding the adrenal gland. The arterial supply appeared constant, with each adrenal gland supplied by up to 60 small arteries. In our series of LA, the main adrenal vein was constant. In 6 cases, the main vein was duplicated. Our cadaver dissection showed the large number of small peripheral veins and arteries surrounding the adrenal gland. Histology confirmed that these peripheral veins drained the adrenal gland.

CONCLUSIONS

After LSA, a nonfunctioning adrenal remnant is unlikely due to an inadequate arterial supply. Division of the main adrenal vein appears safe, but excessive mobilization of the adrenal remnant should be avoided to prevent destruction of the peripheral veins.

Laparoscopic and retroperitoneoscopic treatment of pheochromocytomas and retroperitoneal paragangliomas: results of 161 tumors in 126 patients

BACKGROUND

Laparoscopic and retroperitoneoscopic excisions of pheochromocytomas and retroperitoneal paragangliomas are challenging surgical procedures because of extensive intraoperative catecholamine release, extreme vascularization, and demanding localization.

MATERIALS

In a prospective clinical study 161 chromaffine neoplasias (134 pheochromocytomas, 27 paragangliomas) were removed endoscopically in 126 patients (67 males, 59 females, age 41.7 +/- 16.4 years; 130 operations). Six patients showed multiple (2-5) tumors. Tumor size ranged from 0.5 to 12 cm (mean 3.5 +/- 1.9 cm). Forty-two patients suffered from hereditary diseases. Twenty-four patients had bilateral adrenal diseases; in 14 patients pheochromocytomas were removed on both sides synchroneously. Ten neoplasias were local or loco-regional recurrences (7 pheochromocytomas, 3 paragangliomas). The laparoscopic route was chosen in 16 operations; the retroperitoneoscopic technique was performed in 128 others. Partial adrenalectomies were performed in 57 operations (in all but one of the patients with bilateral disease). High-dosage alpha-blockade with phenoxybenzamine was routinely used.

RESULTS AND DISCUSSION

Conversion to open surgery occurred once. Perioperative complications were minor (17%); mortality was zero. Operating time for unilateral retroperitoneoscopically removed primary pheochromocytomas (n = 113) was 82 +/- 49 minutes (range: 20-300 minutes) and depended on tumor size (< 3 cm vs. > or = 3 cm; P < 0.05) and gender (P < 0.001), but not on extent of resection (partial vs. total, P = 0.266). Operating time for paragangliomas ranged from 55 to 600 minutes. Median blood loss was 20 ml. Median duration of postoperative hospitalization was 4 days. In 22 of 24 patients with bilateral disease, complete preservation of cortical function was achieved. Locoregional and/or distant metastatic recurrence were found in 5 patients.

CONCLUSIONS

Endoscopic removal of solitary, bilateral, multiple, and recurrent pheochromocytomas and retroperitoneal paragangliomas is feasible and safe, but surgeons need extensive experience in minimally invasive techniques, as well as in endocrine surgery.

Laparoscopic partial adrenalectomy for aldosterone-producing adenomas with needlescopic instruments

INTRODUCTION

Laparoscopic total adrenalectomy is the treatment of choice for aldosterone-producing adenomas (APAs). There have not been many reports of laparoscopic partial adrenalectomy, although this procedure offers benefits to patients with suspected bilateral APAs or an APA in a solitary adrenal gland. We describe the feasibility of a novel technique of laparoscopic partial adrenalectomy for APA solely using 2-mm working instruments and a 5 to 10-mm telescope.

TECHNICAL CONSIDERATIONS

Six unilateral and two bilateral partial adrenalectomies were performed laparoscopically. Only one umbilical 12-mm port for the telescope and two (for left adenomas) or three (for right adenomas) subcostal 2-mm working ports were used. Hemostasis and transection of adrenal tissues were performed using a 2-mm mini-bipolar coagulator and 2-mm scissors.

RESULTS

All laparoscopic operations were successfully performed using only 2-mm working instruments and a 5 or 10-mm 30 degree telescope with no intraoperative or postoperative complications. Blood loss was minimal, and the operative times were comparable to those of previous reports. All patients had low pain scores, required minimal amounts of narcotics postoperatively, and reported excellent cosmetic results for the wounds. The pathologic examinations confirmed complete excision of all adenomas with intact capsules. The plasma aldosterone concentrations and renin activities returned to normal ranges postoperatively in all patients. At a mean follow-up of 25 months (range 13 to 48), 7 (87.5%) were cured of their hypertension and 1 had the hypertensive medications significantly reduced.

CONCLUSIONS

Laparoscopic partial adrenalectomy for APAs using 2-mm working instruments and a 5 to 10-mm telescope is a safe and effective treatment alternative.

Laparoscopic adrenalectomy

Laparoscopic adrenalectomy (LA) was first described in the literature in 1992, and has become the preferred method for the removal of benign functioning and non-functioning tumors of the adrenal gland <12 cm. The objectives of the present study are to review the experience of LA gained since it was first done in 1992 and to critically evaluate its effectiveness for the surgical management of endocrine hypertension; specifically pheochromocytoma, aldosteronoma and Cushing's syndrome and disease, as opposed to open adrenalectomy. The benefits of minimally invasive techniques for the removal of the adrenal gland include decreased requirements for analgesics, improved patient satisfaction, shorter hospital stay and recovery time when compared to open surgery. LA can be performed safely for bilateral disease and may become the standard of care for malignant tumors. Current limitations are operator-dependent and not a factor of limitations of minimally invasive techniques. A thorough pre-operative work-up is key for differentiating the various cases of hypertension and adequate pre-operative treatment is paramount when indicated.

Laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the procedure of choice for small benign lesions. Compared with open adrenalectomy (OA), it appears to achieve superior results in terms of recovery, cosmesis and morbidity.

METHODS

A Medline literature search (PubMed database, 1990-2003) was undertaken to identify relevant English language papers. Studies comparing LA with OA were categorized according to their level of evidence. Variables of outcome were analysed systematically for various adrenal pathologies.

RESULTS

No prospective randomized studies comparing LA with OA were identified. According to 20 comparative case-control studies (level 3b) and many case-series reports (level 4), the results of LA were reproducible and it has consistently been associated with faster recovery and lower morbidity than OA. The clinical outcome in hormonally active lesions was similar. The lateral transabdominal approach was the laparoscopic technique of choice; it was practised by 78.6 per cent of surgeons. Lesion sizes of 10-12 cm were cited as the upper limit for LA in many large series. Experience of 70 malignancies demonstrated the feasibility of LA, with short-term oncological results comparable to those of conventional surgery.

CONCLUSION

Despite a lack of a high level of evidence in its favour, LA has practically replaced OA in the management of small and medium-size benign functioning and non-functioning adrenal lesions, as it has proved to be as effective as OA with less associated morbidity. Although limited experience with large and malignant tumours shows some promise, present data are insufficient for clear conclusions to be drawn.

Laparoscopic partial adrenalectomy

Since corticosteroids are indispensable hormones, partial or cortical-sparing adrenalectomies may be adopted for the surgical treatment of adrenal diseases. In this article, we describe the technique and results of these procedures. Laparoscopic partial or cortical-sparing adrenalectomy has been performed in 10 patients. Seven cases had an aldosterone-producing adenoma (APA) and three had a pheochromocytoma. Three cases with an APA and a case with a pheochromocytoma had tumors located far from the adrenal central vein, and the vein could be preserved. Four cases with an APA and two with a pheochromocytoma had tumors located close to the adrenal central vein, and it was necessary to section the central vein to resect them. All endoscopic procedures were performed successfully. There were no postoperative complications. At follow-up, adrenal 131I-adosterol scintigrams showed the preservation of remnant adrenal function in all patients. Laparoscopic partial or cortical-sparing adrenal surgery was safely performed, and adrenal function was preserved irrespective of whether the adrenal central vein could be preserved or not. We consider this to be a useful operative technique for selected cases.

Laparoscopic partial adrenalectomy in patients with aldosterone-producing adenomas: indications, technique, and results

OBJECTIVES

To report the indications, technique, and results in patients with primary hyperaldosteronism due to aldosterone-producing adrenal adenoma treated by laparoscopic partial adrenalectomy. Laparoscopy has become the technique of choice in adrenal surgery, but adrenalectomy is the standard procedure. Only a few studies have reported on partial adrenalectomy, and the indications and technique have not yet been clearly defined.

METHODS

From June 1995 to December 2001, 13 patients presented with hyperaldosteronism and a single adrenal adenoma (Conn's syndrome) and were treated with laparoscopic partial adrenalectomy. The mean age was 60 years, and the average tumor size was 2.1 cm in diameter. A transperitoneal approach was used in all patients, tumors were resected with safety margins by endoshears, and hemostasis was achieved by bipolar coagulation and finally by sealing with fibrin glue.

RESULTS

All procedures were finished laparoscopically, and no conversion was necessary. No major intraoperative or postoperative complication was observed. The histologic examination showed adenomas with negative surgical margins in all cases. Postoperative computed tomography revealed a normal blood supply for the remaining adrenal tissue. Blood pressure and aldosterone levels were unremarkable at follow-up, and no local recurrence was observed.

CONCLUSIONS

Laparoscopic partial adrenalectomy for aldosterone-producing adenomas is a minimally invasive procedure with a low complication rate. It provides the benefit of retaining functional tissue on the side of the affected adrenal gland. Therefore, we recommend laparoscopic partial adrenalectomy for patients with small, potentially benign, tumors of the adrenal gland, even with a healthy contralateral adrenal gland.

Intraoperative ultrasound aids in dissection during laparoscopic partial adrenalectomy

PURPOSE

Adrenal cortical sparing surgery is a relatively new approach to adrenal tumors. Laparoscopic partial nephrectomy is a technically feasible but challenging operation. We describe the use of intraoperative ultrasound to facilitate laparoscopic partial nephrectomy in a population with a hereditary predisposition to multifocal pheochromocytoma.

MATERIALS AND METHODS

All patients underwent a history, physical examination, serum and urine catecholamine determinations, abdominal computerized tomography-magnetic resonance imaging and metaiodobenzylguanidine scan. The adrenal gland was exposed using a standard 3 or 4 port approach. Intraoperative ultrasound was performed using a 7.5 MHz. 10 mm. transducer placed through a 12 mm. port. After imaging the whole gland and adjacent structures partial adrenalectomy was performed based on intraoperative ultrasound images using a harmonic scalpel or alternatively using a cut and sew technique that provided a 5 mm. margin. Tumors were removed intact and sent for pathological examination.

RESULTS

Since 1998, 11 patients have undergone laparoscopic partial adrenalectomy. Intraoperative ultrasound was performed in 7 patients with suspected multiple adrenal masses, including 4 and 3 who underwent unilateral and bilateral laparoscopic partial nephrectomy, respectively. Six of the 7 patients had germline defects in the von Hippel-Lindau disease gene and 1 had no identifiable alteration in the von Hippel-Lindau disease or RET gene. A solitary tumor was identified in 3 cases and multiple lesions were noted in 4. In 1 case intraoperative ultrasound localized a tumor not identified on preoperative imaging that was not readily visible via laparoscopy. Intraoperative ultrasound guided surgical dissection in all cases and identified an extra-adrenal mass in 1 patient with bilateral adrenal masses. There were no complications due to intraoperative ultrasound and no conversions to open surgery. Mean operative time was 335 minutes and mean estimated blood loss was 179 ml. Histological study demonstrated pheochromocytoma in 14 lesions and the extra-adrenal mass proved to be a splenic rest. At short-term followup no recurrences have been noted. All patients retained sufficient adrenal cortical function to avoid steroid replacement therapy.

CONCLUSIONS

Laparoscopic ultrasound differentiates normal adrenal parenchyma from adrenal tumors and facilitates laparoscopic partial adrenalectomy.