[Laparoscopic adrenalectomy--experience of 10 years]

Laparoscopic adrenalectomy for the management of benign and malignant adrenal tumors

Laparoscopic adrenalectomy has become the preferred approach for removal of the adrenal gland. Many published studies support the use of laparoscopic adrenalectomy, with comparisons to open adrenalectomy suggesting many advantages to laparoscopy, including less postoperative pain, shorter hospital stay and earlier return to work. Adrenalectomy is usually required for the removal of adrenal tumors causing excess hormone production or because a malignant adrenal tumor cannot be excluded. Current controversies include the appropriateness of laparoscopic adrenalectomy for large or malignant tumors, the role of partial adrenalectomy and the management of some conditions with uncertain natural history (such as subclinical hypercortisolism). With the increased use of sensitive cross-sectional imaging, the detection of clinically inapparent adrenal masses is likely to continue to increase. Due to the fact that malignancy cannot be excluded with certainty in some patients with cortical adenomas, it is expected that the rate of laparoscopic adrenalectomy will continue to increase.

Risk of catecholamine crisis in patients undergoing resection of unsuspected pheochromocytoma

PURPOSE

To report the risk of catecholamine crisis in patients undergoing resection of unsuspected pheochromocytoma.

MATERIALS AND METHODS

Over a four-year period, we retrospectively identified four patients who underwent resection of adrenal pheochromocytoma in whom the diagnosis was unsuspected based on preoperative clinical, biochemical, and imaging evaluation.

RESULTS

None of the patients exhibited preoperative clinical features of catecholamine excess. Preoperative biochemical screening in two patients was normal. CT scan performed in all patients demonstrated a nonspecific enhancing adrenal mass. During surgical resection of the adrenal mass, hemodynamic instability was observed in two of four patients, and one of these two patients also suffered a myocardial infarct.

CONCLUSION

Both surgeons and radiologists should maintain a high index of suspicion for pheochromocytoma, as the tumor can be asymptomatic, biochemically negative, and have nonspecific imaging features. Resection of such unsuspected pheochromocytomas carries a substantial risk of intraoperative hemodynamic instability.

Laparoscopic adrenalectomy: Gaining experience by graded approach

INTRODUCTION

Laparoscopic adrenalectomy (LA) has become a gold standard in management of most of the adrenal disorders. Though report on the first laparoscopic adrenalectomy dates back to 1992, there is no series of LA reported from India. Starting Feb 2001, a graded approach to LA was undertaken in our center. Till March 2006, a total of 34 laparoscopic adrenalectomies were performed with success.

MATERIALS AND METHODS

The endocrinology department primarily evaluated all patients. Patients were divided into Group A - unilateral LA and Group B - bilateral LA (BLA). The indications in Group A were pheochromocytoma (n=7), Conn's syndrome (n=3), Cushing's adenoma (n=2), incidentaloma (n=2); and in Group B, Cushing's disease (CD) following failed trans-sphenoid pituitary surgery (n = 8); ectopic ACTH- producing Cushing's syndrome (n=1) and congenital adrenal hyperplasia (CAH) (n=1). The lateral transabdominal route was used.

RESULTS

The age group varied from 12-54 years, with mean age of 28.21 years. Average duration of surgery in Group A was 166.43 min (40-270 min) and 190 min (150-310 min) in Group B. Average blood loss was 136.93 cc (20-400 cc) in Group A and 92.5 cc (40-260 cc) in Group B. There was one conversion in each group. Mean duration of surgical stay was 1.8 days (1-3 days) in Group A and 2.6 days (2-4 days) in Group B. All the patients in both groups were cured of their illness. Three patients in Group B developed Nelson's syndrome. The mean follow up was of 24.16 months (4-61 months).

CONCLUSION

LA though technically demanding, is feasible and safe. Graded approach to LA is the key to success.

Has experience changed the scenario in laparoscopic adrenalectomy?

BACKGROUND

Laparoscopic adrenalectomy (LA) is a relatively uncommon operation performed by surgeons with a specific interest in endocrine surgery as well as advanced laparoscopic surgery. LA is technically difficult and it is recommended to tackle small glands first till adequate experience is reached [1]. A minimum of 30 cases are required to master the technique [2]. The present study reviews data of 60 laparoscopic adrenalectomies comparing the later results with the first 30 cases.

MATERIAL AND METHODS

Starting 2001, patients diagnosed to have adrenal disorders were subjected to laparoscopic approach in a graded manner. A database was maintained with respect to age, sex, duration of symptoms, co-morbid conditions, diagnosis, size of tumor, weight of tumor, blood loss, duration of surgery, conversion to open, in-hospital stay, referral pattern, morbidity (both early and late) and mortality. The database was divided into two groups. First 30 patients constituted Group A, Group B constituted the next 30 adrenalectomies and deviation in the two was noted. Statistical analysis was performed to determine the importance of deviation of factors.

RESULTS

Sixty adrenalectomies were performed in 49 patients (11 being bilateral) between February 2001 and July 2008. Age group varied from 12-54 years with mean of 30.73 years, Twenty four were males. Thirty-one right and 29 left LA were performed. The comparison of factors in relation to the two groups (Group A and B respectively) revealed an increase in number of adrenalectomies performed (0.4 v/s 0.76) in relation to timeline, increased incidence of pheochromocytoma (6 v/s 18) and incidentalomas (zero v/s 8), larger tumor size (4.17 cm v/s 6.6 cm), comparable blood loss (72 cc v/s 98.3 cc) and duration of surgery (122 min v/s 112 min), increased conversion to open surgery (1 v/s 6) leading to increased in-hospital stay (2.8 days v/s 3.37 days) but a comparable morbidity (2 v/s 1) and no mortality.

CONCLUSION

Though technically difficult, with increasing experience and focused approach, laparoscopic skills in adrenalectomy improves. The spectrum of indications broadens, thus making laparoscopic interventions for vascular and large adrenal glands safe and patient friendly.

Experience of retroperitoneoscopic adrenalectomy in 195 patients with primary aldosteronism

OBJECTIVES

Laparoscopic adrenalectomy has become an effective option for aldosteronoma. We evaluated the retroperitoneal approach with regard to safety, efficacy, invasiveness and cost-benefit ratio in patients with primary aldosteronism.

METHODS

Between July 1999 and June 2005, we carried out a total of 195 retroperitoneoscopic adrenalectomies (RA) in one hospital, including 108 on the left and 87 on the right, in 78 men and 113 women aged 20-78 years (mean age 48.2 years) with aldosteronoma. Average adrenal tumor size was 16 mm (range 10-32 mm). The 195 operations were divided into 10 groups of 20 operations each, and the mean duration and estimated blood loss for each group were compared.

RESULTS

The mean operating time and intraoperative blood loss in RA were 93.2 +/- 37.4 (45-210) min and 68.5 +/- 53.2 (5-210) mL, respectively. Compared to group 1 (cases 1-20), a statistically significant decrease in operative time and estimated blood loss were seen in and after group 4 (>or= case 61, 94.5 +/- 30.3 vs 139.2 +/- 44.7 min, P < 0.01), and in and after group 5 (>or= case 81, 67.5 +/- 50.5 vs 120.5 +/- 60.9 mL, P < 0.01), respectively. No differences were found in duration of surgery and estimated blood loss between left and right sided tumors (P > 0.05). The mean postoperative hospital stay was 4.5 +/- 1.2 days. Postoperative complications, including hematoma and wound infection, occurred in 4.1% of patients.

CONCLUSIONS

Retroperitoneoscopic adrenalectomy for aldosteronoma is a safe, effective, and minimally invasive approach with an advantageous cost-benefit ratio. With accumulated experience, it can expedite the learning curve for RA.