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Thoracoscopic transdiaphragmatic approach for adrenal biopsy
Thoracoscopic Transdiaphragmatic Approach for Adrenal Biopsy Michael J. Mack, MD, Ronald J. Aronoff, MD, Tea E. Acuff, MD, and William H. Ryan, MD Section of Thoracic Surgery, Humana Hospital Medical City Dallas, Dallas, Texas
The role of thoracoscopy for the management of intrathoracic diseases has expanded with advancement in endoscopic instrumentation and technology. We report a case of thoracoscopic transdiaphragmatic biopsy of an adrenal gland for metastatic carcinoma. The procedure was uncomplicated and the patient was discharged on the sec-
ond postoperative day. The morbidity of traditional approaches for adrenal operation was avoided. Thoracoscopy may be a useful approach in selected patients for adrenal operation.
N
superiorly, and an enlarged adrenal gland was identified. An endoscopic fan retractor was used to facilitate exposure. The blood supply to the adrenal gland was managed with endoscopic surgical clips. A biopsy forceps was used to obtain tissue for microscopic analysis, which confirmed metastatic adenocarcinoma in the adrenal gland. The procedure was terminated at that point, but if indicated, complete resection of the adrenal gland could have been easily accomplished. The diaphragm was then reapproximated using the endoscopic hernia stapler (Endo Hernia Stapler; United States Surgical Corp). A chest tube was not used, and the trocar sites were closed with an absorbable subcuticular suture. Total operating time was 135 minutes. The patient's postoperative course was unremarkable. He was discharged on the morning of the second postoperative day. No parenteral pain medication was required to manage the mild incisional discomfort. The patient resumed full activity on the fourth postoperative day and is presently undergoing chemotherapy. A chest roentgenogram remains normal 4 months postoperatively with no evidence of diaphragmatic herniation.
umerous surgical approaches to the adrenal gland have been described including anterior, posterior, flank, and thoracoabdominal techniques [11. Advances in endoscopic surgical instrumentation have expanded the role of thoracoscopy in the management of many intrathoracic conditions. This report describes the successful thoracoscopic transdiaphragmatic biopsy of an adrenal gland. A 58-year-old man presented with a new left adrenal mass. The patient had a history of a right colectomy for adenocarcinoma 6 years previously. He had a recurrence in his liver, which was successfully treated with intrahepatic 5-fluorouracil. Six months before presentation, he had resection of three metastases in his right lung by thoracoscopic laser techniques. By computed tomography performed in follow-up after this procedure, a new 3.0-cm mass in his left adrenal gland was discovered (Fig 1). A percutaneous needle biopsy of the mass yielded normal adrenal tissue. To gain tissue confirmation of metastatic disease an open biopsy was thought to be indicated. After induction of anesthesia, a double-lumen endotracheal tube was used to collapse the left lung. A 10-mm telescope and camera (OTV-52; Olympus Corp, Lake Success, NY)was introduced into the chest through a trocar (Surgiport; United States Surgical Corp, Norwalk, CT) placed posterior to the midaxillary line in the ninth intercostal space. No intrathoracic abnormalities were observed. Two additional trocars were placed anteriorly and posteriorly in the ninth and tenth intercostal spaces as access for endoscopic scissors and grasping instruments. A 6-cm radial incision was made posteriorly in the diaphragm to access the retroperitoneum. Using careful sharp and blunt dissection, exploration of the retroperitoneal fat was undertaken until Gerota's fascia was identified. The fascia was opened Accepted for publication June 1, 1992. Address reprint requests to Dr Mack, 7777 Forest Ln, Suite C-202, Dallas, TX 75230.
0 1993 by The Society of Thoracic Surgeons
(Ann Thorac Surg 1993;55:772-3)
Comment Thoracoscopy has had a limited application, until recently, for management of intrathoracic diseases. Improvement in optics, video technology, endoscopic lighting sources, and endoscopic instrumentation have expanded the role of thoracoscopy to include procedures involving the lung, pericardium and mediastinum, and pleura [2]. There are multiple indications for surgical intervention on the adrenal gland. The approach is partially dictated by the adrenal pathology. The anterior transabdominal approach is indicated for lesions that are either large or potentially malignant. It is also indicated for pheochromocytoma to allow for early vascular control and to allow for exploration for bilateral or extraadrenal tumors [3]. The posterior surgical approach was described by OOO3-4975/93/$6.00
CASE REPORT MACK ET AL THORACOSCOPIC ADRENAL BIOPSY
Ann Thorac Surg 1993;55:72-3
Fig 1 . Computed tomogram demonstrating a left adrenal mass (arrow).
Young [4] more than 50 years ago and is anatomically the most direct route to the adrenal gland. Although the morbidity of this approach is less than with the anterior route, the operative field is relatively small and exposure is restricted. A flank incision has been advocated as being helpful for adrenalectomy in obese patients [3]. The thoracoabdominal approach is usually reserved for large right-sided adrenal masses. The morbidity associated with adrenalectomy can be as high as 40%, and the mortality is approximately 2%to 4% depending on the indication and approach [5, 61. The morbidity and pain associated with traditional surgical incisions serve as an impetus to minimally invasive surgical techniques. Thoracoscopy offers the advantage of lessened morbidity from the surgical incision, yet excellent exposure of the retroperitoneum due to optics, magnification, and lighting. The thoracoscopic approach would not be indicated in patients with pheochromocytoma or large adrenal masses for resection. There are, however, a select group of patients in whom this may become the preferred technique. In our case, we performed a limited biopsy on the
773
adrenal gland only after a percutaneous needle biopsy was nondiagnostic. Enlarged adrenal glands are encountered in otherwise operable patients (4.1%) with non-small cell lung cancer [7].Frequently, there is discovered pathology other than metastatic carcinoma including adenomas, hyperplastic nodules, and cysts. Preoperative percutaneous needle biopsy should first be performed. If nondiagnostic, thoracoscopy at the time of anticipated lung resection could then be used to obtain a definite tissue diagnosis if both lesions were on the same side. Reyes and associates [8] have reported prolonged survival of 5 patients with lung cancer and adrenal metastases in whom the primary tumor was resected and adrenalectomy performed. Both resections could be managed by thoracoscopy. In summary, thoracoscopy offers a new approach for operation on the adrenal gland. More experience is necessary before the scope of procedures possible can be determined. In selected patients, the thoracoscopic transdiaphragmatic approach offers lessened morbidity and superior visualization compared with open approaches. As minimally invasive surgical techniques improve, continued modification of standard surgical approaches is likely to happen.
References 1. Hughes S , Lynn J. The surgical treatment of adrenal disease. Br J Hosp Med 1989;41:350-6. 2. Landreneau RJ, Herlan DB, Johnson JA, Boley TM, Nawarawong W, Ferson PF. Thoracoscopic neodymium:yttriumaluminum garnet laser-assisted pulmonary resection. Ann Thorac Surg 1991;52117&8. 3. Guz BV, Straffon RA, Novick AC. Operative approaches to the adrenal gland. Urol Clin North Am 1989;16:527-34. 4. Young HH. A technique for simultaneous exposure and operation on the adrenals. Surg Gynecol Obstet 1936;54:179. 5. McLeod MK. Complications following adrenal surgery. J Natl Med Assoc 1989;83:1614. 6. Angermeier KW, Montie JE. Perioperative complications of adrenal surgery. Urol Clin North Am 1989;16:597-606. 7. Ettinghausen SE, Burt ME. Prospective evaluation of unilateral adrenal masses in patients with operable non-small cell lung cancer. J Clin Oncol 1991;9:1462-6. 8. Reyes L, Parvez Z, Nemoto T, Regal AM, Takita H. Adrenalectomy for adrenal metastasis from lung carcinoma. J Surg Oncol 1990;44:324.
The role of thoracoscopy for the management of intrathoracic diseases has expanded with advancement in endoscopic instrumentation and technology. We report a case of thoracoscopic transdiaphragmatic biopsy of an adrenal gland for metastatic carcinoma. The procedure was uncomplicated and the patient was discharged on the sec-
ond postoperative day. The morbidity of traditional approaches for adrenal operation was avoided. Thoracoscopy may be a useful approach in selected patients for adrenal operation.
N
superiorly, and an enlarged adrenal gland was identified. An endoscopic fan retractor was used to facilitate exposure. The blood supply to the adrenal gland was managed with endoscopic surgical clips. A biopsy forceps was used to obtain tissue for microscopic analysis, which confirmed metastatic adenocarcinoma in the adrenal gland. The procedure was terminated at that point, but if indicated, complete resection of the adrenal gland could have been easily accomplished. The diaphragm was then reapproximated using the endoscopic hernia stapler (Endo Hernia Stapler; United States Surgical Corp). A chest tube was not used, and the trocar sites were closed with an absorbable subcuticular suture. Total operating time was 135 minutes. The patient's postoperative course was unremarkable. He was discharged on the morning of the second postoperative day. No parenteral pain medication was required to manage the mild incisional discomfort. The patient resumed full activity on the fourth postoperative day and is presently undergoing chemotherapy. A chest roentgenogram remains normal 4 months postoperatively with no evidence of diaphragmatic herniation.
umerous surgical approaches to the adrenal gland have been described including anterior, posterior, flank, and thoracoabdominal techniques [11. Advances in endoscopic surgical instrumentation have expanded the role of thoracoscopy in the management of many intrathoracic conditions. This report describes the successful thoracoscopic transdiaphragmatic biopsy of an adrenal gland. A 58-year-old man presented with a new left adrenal mass. The patient had a history of a right colectomy for adenocarcinoma 6 years previously. He had a recurrence in his liver, which was successfully treated with intrahepatic 5-fluorouracil. Six months before presentation, he had resection of three metastases in his right lung by thoracoscopic laser techniques. By computed tomography performed in follow-up after this procedure, a new 3.0-cm mass in his left adrenal gland was discovered (Fig 1). A percutaneous needle biopsy of the mass yielded normal adrenal tissue. To gain tissue confirmation of metastatic disease an open biopsy was thought to be indicated. After induction of anesthesia, a double-lumen endotracheal tube was used to collapse the left lung. A 10-mm telescope and camera (OTV-52; Olympus Corp, Lake Success, NY)was introduced into the chest through a trocar (Surgiport; United States Surgical Corp, Norwalk, CT) placed posterior to the midaxillary line in the ninth intercostal space. No intrathoracic abnormalities were observed. Two additional trocars were placed anteriorly and posteriorly in the ninth and tenth intercostal spaces as access for endoscopic scissors and grasping instruments. A 6-cm radial incision was made posteriorly in the diaphragm to access the retroperitoneum. Using careful sharp and blunt dissection, exploration of the retroperitoneal fat was undertaken until Gerota's fascia was identified. The fascia was opened Accepted for publication June 1, 1992. Address reprint requests to Dr Mack, 7777 Forest Ln, Suite C-202, Dallas, TX 75230.
0 1993 by The Society of Thoracic Surgeons
(Ann Thorac Surg 1993;55:772-3)
Comment Thoracoscopy has had a limited application, until recently, for management of intrathoracic diseases. Improvement in optics, video technology, endoscopic lighting sources, and endoscopic instrumentation have expanded the role of thoracoscopy to include procedures involving the lung, pericardium and mediastinum, and pleura [2]. There are multiple indications for surgical intervention on the adrenal gland. The approach is partially dictated by the adrenal pathology. The anterior transabdominal approach is indicated for lesions that are either large or potentially malignant. It is also indicated for pheochromocytoma to allow for early vascular control and to allow for exploration for bilateral or extraadrenal tumors [3]. The posterior surgical approach was described by OOO3-4975/93/$6.00
CASE REPORT MACK ET AL THORACOSCOPIC ADRENAL BIOPSY
Ann Thorac Surg 1993;55:72-3
Fig 1 . Computed tomogram demonstrating a left adrenal mass (arrow).
Young [4] more than 50 years ago and is anatomically the most direct route to the adrenal gland. Although the morbidity of this approach is less than with the anterior route, the operative field is relatively small and exposure is restricted. A flank incision has been advocated as being helpful for adrenalectomy in obese patients [3]. The thoracoabdominal approach is usually reserved for large right-sided adrenal masses. The morbidity associated with adrenalectomy can be as high as 40%, and the mortality is approximately 2%to 4% depending on the indication and approach [5, 61. The morbidity and pain associated with traditional surgical incisions serve as an impetus to minimally invasive surgical techniques. Thoracoscopy offers the advantage of lessened morbidity from the surgical incision, yet excellent exposure of the retroperitoneum due to optics, magnification, and lighting. The thoracoscopic approach would not be indicated in patients with pheochromocytoma or large adrenal masses for resection. There are, however, a select group of patients in whom this may become the preferred technique. In our case, we performed a limited biopsy on the
773
adrenal gland only after a percutaneous needle biopsy was nondiagnostic. Enlarged adrenal glands are encountered in otherwise operable patients (4.1%) with non-small cell lung cancer [7].Frequently, there is discovered pathology other than metastatic carcinoma including adenomas, hyperplastic nodules, and cysts. Preoperative percutaneous needle biopsy should first be performed. If nondiagnostic, thoracoscopy at the time of anticipated lung resection could then be used to obtain a definite tissue diagnosis if both lesions were on the same side. Reyes and associates [8] have reported prolonged survival of 5 patients with lung cancer and adrenal metastases in whom the primary tumor was resected and adrenalectomy performed. Both resections could be managed by thoracoscopy. In summary, thoracoscopy offers a new approach for operation on the adrenal gland. More experience is necessary before the scope of procedures possible can be determined. In selected patients, the thoracoscopic transdiaphragmatic approach offers lessened morbidity and superior visualization compared with open approaches. As minimally invasive surgical techniques improve, continued modification of standard surgical approaches is likely to happen.
References 1. Hughes S , Lynn J. The surgical treatment of adrenal disease. Br J Hosp Med 1989;41:350-6. 2. Landreneau RJ, Herlan DB, Johnson JA, Boley TM, Nawarawong W, Ferson PF. Thoracoscopic neodymium:yttriumaluminum garnet laser-assisted pulmonary resection. Ann Thorac Surg 1991;52117&8. 3. Guz BV, Straffon RA, Novick AC. Operative approaches to the adrenal gland. Urol Clin North Am 1989;16:527-34. 4. Young HH. A technique for simultaneous exposure and operation on the adrenals. Surg Gynecol Obstet 1936;54:179. 5. McLeod MK. Complications following adrenal surgery. J Natl Med Assoc 1989;83:1614. 6. Angermeier KW, Montie JE. Perioperative complications of adrenal surgery. Urol Clin North Am 1989;16:597-606. 7. Ettinghausen SE, Burt ME. Prospective evaluation of unilateral adrenal masses in patients with operable non-small cell lung cancer. J Clin Oncol 1991;9:1462-6. 8. Reyes L, Parvez Z, Nemoto T, Regal AM, Takita H. Adrenalectomy for adrenal metastasis from lung carcinoma. J Surg Oncol 1990;44:324.