Intraoperative Ultrasound Aids in Dissection During Laparoscopic Partial Adrenalectomy:

Laparoscopic enucleation of macronodules in a patient with ACTH-independent macronodular adrenal hyperplasia 7 years after unilateral adrenalectomy: consideration of operative procedure

OBJECTIVES

We evaluated the technical feasibility and efficacy of laparoscopic enucleation of adrenal macronodules in a patient with ACTH-independent macronodular adrenal hyperplasia (AIMAH).

PATIENT AND METHODS

A 41-year-old female manifested Cushing's syndrome due to AIMAH in 1999 and underwent a right unilateral adrenalectomy in 2002. Although the patient's symptoms improved postoperatively, in 2005 they began to get worse as her urinary cortisol excretion increased. Computed tomography in 2008 showed four macronodules in the left adrenal gland, and we performed a laparoscopic enucleation of four adrenal nodules in hopes of avoiding the need for lifelong steroid replacement. In the operation we paid special attention to avoiding injuring major adrenal vessels. Nontumorous adrenal tissue was dissected just near the surfaces of the nodules by using a sealing system. The residual adrenal gland was at most left undissected from the surrounding tissues in order to preserve blood supply and preserve small drainage veins.

RESULTS

The operation could be performed with minimal blood loss. Plasma cortisol became measurable 22 months after the enucleation and returned to normal level 29 months after the enucleation.

CONCLUSIONS

The laparoscopic enucleation of hyperplastic nodules is technically feasible and a treatment of choice for AIMAH patients who already underwent unilateral adrenalectomy.

Extent of adrenalectomy for adrenal neoplasm: cortical sparing (subtotal) versus total adrenalectomy

The standard operation on adrenal neoplasias is a complete adrenalectomy. Accepted exceptions are bilateral inherited pheochromocytomas. In these cases, clinical and biochemical cure, as well as preservation of cortical function, can be achieved by a noncomplete adrenalectomy. In that procedure, at least one third of one gland has to be preserved. In unilateral adrenal tumors, partial resection has been used, especially in Conns adenomas, with early results comparable to those of total adrenalectomy. Because longterm results are still limited in hyperaldosteronism, final conclusions are not possible today.