- Email: [email protected]
Invited Commentary: On “Posterior retroperitoneoscopic adrenalectomy—results of 560 procedures in 520 patients”
Invited Commentary: On “Posterior retroperitoneoscopic adrenalectomy— results of 560 procedures in 520 patients” Douglas B. Evans, MD, and Nancy D. Perrier, MD, Houston, TX From the University of Texas M.D. Anderson Cancer Center
Laparoscopic adrenalectomy has become the favored technique for removal of the adrenal gland in patients with benign functioning cortical adenomas, pheochromocytomas, aldosterone-producing adenomas, bilateral adrenal hyperplasia due to Cushing’s disease (in patients who have failed pituitary operation), and in selected patients with isolated adrenal metastases most commonly from lung or malignant melanoma. A trans-abdominal laparoscopic adrenalectomy requires that the organs anterior to the adrenal gland be moved out of the way. On the left, this involves medial rotation of the spleen and pancreas and on the right the liver is mobilized to expose the adrenal gland. These maneuvers require time and dissection of multiple tissue planes. Therefore, it may take 2 hours or more to successfully remove an adrenal neoplasm laparoscopically. In contrast to the traditional trans-abdominal laparoscopic approach carried out with the patient in a lateral position, Professor Martin Walz and colleagues from Essen, Germany report, in this issue of the Journal, their experience with 560 adrenalectomies carried out in 520 patients through the posterior retroperitoneoscopic approach. Professor Walz developed this technique in the animal laboratory and introduced it into clinical operation in 1994. As nicely described in their manuscript, patients are in the prone position and the adrenalectomy is carried out through 3 Accepted for publication August 28, 2006. Reprint requests: Douglas B. Evans, MD, M.D. Anderson Cancer Center, Department of Surgical Oncology, University of Texas, 1515 Holcombe Blvd., Box 444, Houston, TX 77030. E-mail: [email protected]. Surgery 2006;140:951-52. 0039-6060/$ - see front matter © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2006.08.005
trocars placed below the eleventh and twelfth ribs. In the development of this technique, Professor Walz noted that high pressure (20 to 25 mm Hg) was needed to develop the retroperitoneal space adequately. The increased pressure not only provides excellent exposure but also minimizes bleeding from small vessels resulting in a relatively bloodless field and the infrequent need for suction or irrigation. Importantly, if conversion to an open technique should be necessary the patient can be converted to an open posterior approach through the bed of the twelfth rib thereby obviating the need for a trans-abdominal operation. This is particularly attractive in patients undergoing bilateral adrenalectomy for Cushing’s disease in whom a trans-abdominal operation would be of much greater risk due to the chronic effects of excess glucocorticoids on tissues and end-organ function. The posterior retroperitoneoscopic approach is also favored in patients who have undergone multiple prior abdominal operations, and in those who have undergone a partial adrenalectomy and experience a subsequent recurrence as can occur in patients with inherited pheochromocytoma (multiple endocrine neoplasia type 2 or von Hippel-Lindau Syndrome) who have undergone a cortical-sparing adrenalectomy. Despite a previous open or laparoscopic trans-abdominal approach to the adrenal gland, recurrent pheochromocytoma can be removed through the posterior retroperitoneoscopic technique as shown in 7 patients in the author’s experience. Professor Walz cautions the reader with regard to the contraindications for a posterior retroperitoneoscopic approach, listing 3 relative contraindications, including large tumor size, obesity, and the presence of a primary malignant adrenal neoplasm. Although Professor Walz has removed tumors up to 7 cm in size, it is safe to say that for SURGERY 951
952 Evans and Perrier
those of us less experienced with this technique, a smaller size limit would be more appropriate. In addition, functioning and non-functioning cortical neoplasms that are thought to be malignant based on preoperative imaging (tumor size, and CT/MRI characteristics) are best managed through an open trans-abdominal approach. Although the exposure through the posterior retroperitoneoscopic approach is excellent, the space in which to maneuver instruments and retract the tumor is somewhat modest. Therefore, as the tumor size increases, one can envision a greater likelihood of tumor manipulation. Because adrenal cortical carcinomas are typically larger in size (usually ⬎4 cm), it is more difficult and oncologically less attractive to consider this technique in patients in whom primary adrenal cortical carcinoma is on the list of differential diagnoses. The advantages of this approach in patients with benign primary tumors of the adrenal gland, however, will likely make retroperitoneoscopic adrenalectomy the technique of choice; as stated by Professor Walz, the decreased operative time, the low conversion rate, and the minimal dissection of surrounding tissues are advantages unique to this method of adrenalectomy. In addition, the possibility of performing a subtotal resection, when necessary, remains available. Technical points that gain obvious importance when one either observes or attempts this opera-
Surgery December 2006
tion and are not easily conveyed in a manuscript or book chapter, include trocar placement, identification and gentle downward retraction of the kidney, maintenance of the horizon by an experienced cameraman (especially important when dealing with an anatomic region that is unfamiliar), and identification and division of the adrenal vein early in the operation when the adrenal remains attached superiorly and laterally. As shown in Figure 3 of the manuscript, when operative time is used as a measure of the learning curve, this operation can be challenging when one’s experience is modest. Importantly, the technical nuances of trocar placement, patient positioning, and the initial operative dissection, are critical to the successful performance of this operation and difficult to convey accurately even in a video. Professor Walz and the members of his Institute for Minimally Invasive Surgery at The University Clinic of Essen deserve tremendous credit for developing and perfecting a technique which allows for the safe and rapid removal of benign primary adrenal neoplasms with minimal dissection and virtually no blood loss, while affording the surgeon excellent exposure. In our modest experience with this technique at the University of Texas M.D. Anderson Cancer Center, few patients have required more than an overnight hospital stay.
Laparoscopic adrenalectomy has become the favored technique for removal of the adrenal gland in patients with benign functioning cortical adenomas, pheochromocytomas, aldosterone-producing adenomas, bilateral adrenal hyperplasia due to Cushing’s disease (in patients who have failed pituitary operation), and in selected patients with isolated adrenal metastases most commonly from lung or malignant melanoma. A trans-abdominal laparoscopic adrenalectomy requires that the organs anterior to the adrenal gland be moved out of the way. On the left, this involves medial rotation of the spleen and pancreas and on the right the liver is mobilized to expose the adrenal gland. These maneuvers require time and dissection of multiple tissue planes. Therefore, it may take 2 hours or more to successfully remove an adrenal neoplasm laparoscopically. In contrast to the traditional trans-abdominal laparoscopic approach carried out with the patient in a lateral position, Professor Martin Walz and colleagues from Essen, Germany report, in this issue of the Journal, their experience with 560 adrenalectomies carried out in 520 patients through the posterior retroperitoneoscopic approach. Professor Walz developed this technique in the animal laboratory and introduced it into clinical operation in 1994. As nicely described in their manuscript, patients are in the prone position and the adrenalectomy is carried out through 3 Accepted for publication August 28, 2006. Reprint requests: Douglas B. Evans, MD, M.D. Anderson Cancer Center, Department of Surgical Oncology, University of Texas, 1515 Holcombe Blvd., Box 444, Houston, TX 77030. E-mail: [email protected]. Surgery 2006;140:951-52. 0039-6060/$ - see front matter © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2006.08.005
trocars placed below the eleventh and twelfth ribs. In the development of this technique, Professor Walz noted that high pressure (20 to 25 mm Hg) was needed to develop the retroperitoneal space adequately. The increased pressure not only provides excellent exposure but also minimizes bleeding from small vessels resulting in a relatively bloodless field and the infrequent need for suction or irrigation. Importantly, if conversion to an open technique should be necessary the patient can be converted to an open posterior approach through the bed of the twelfth rib thereby obviating the need for a trans-abdominal operation. This is particularly attractive in patients undergoing bilateral adrenalectomy for Cushing’s disease in whom a trans-abdominal operation would be of much greater risk due to the chronic effects of excess glucocorticoids on tissues and end-organ function. The posterior retroperitoneoscopic approach is also favored in patients who have undergone multiple prior abdominal operations, and in those who have undergone a partial adrenalectomy and experience a subsequent recurrence as can occur in patients with inherited pheochromocytoma (multiple endocrine neoplasia type 2 or von Hippel-Lindau Syndrome) who have undergone a cortical-sparing adrenalectomy. Despite a previous open or laparoscopic trans-abdominal approach to the adrenal gland, recurrent pheochromocytoma can be removed through the posterior retroperitoneoscopic technique as shown in 7 patients in the author’s experience. Professor Walz cautions the reader with regard to the contraindications for a posterior retroperitoneoscopic approach, listing 3 relative contraindications, including large tumor size, obesity, and the presence of a primary malignant adrenal neoplasm. Although Professor Walz has removed tumors up to 7 cm in size, it is safe to say that for SURGERY 951
952 Evans and Perrier
those of us less experienced with this technique, a smaller size limit would be more appropriate. In addition, functioning and non-functioning cortical neoplasms that are thought to be malignant based on preoperative imaging (tumor size, and CT/MRI characteristics) are best managed through an open trans-abdominal approach. Although the exposure through the posterior retroperitoneoscopic approach is excellent, the space in which to maneuver instruments and retract the tumor is somewhat modest. Therefore, as the tumor size increases, one can envision a greater likelihood of tumor manipulation. Because adrenal cortical carcinomas are typically larger in size (usually ⬎4 cm), it is more difficult and oncologically less attractive to consider this technique in patients in whom primary adrenal cortical carcinoma is on the list of differential diagnoses. The advantages of this approach in patients with benign primary tumors of the adrenal gland, however, will likely make retroperitoneoscopic adrenalectomy the technique of choice; as stated by Professor Walz, the decreased operative time, the low conversion rate, and the minimal dissection of surrounding tissues are advantages unique to this method of adrenalectomy. In addition, the possibility of performing a subtotal resection, when necessary, remains available. Technical points that gain obvious importance when one either observes or attempts this opera-
Surgery December 2006
tion and are not easily conveyed in a manuscript or book chapter, include trocar placement, identification and gentle downward retraction of the kidney, maintenance of the horizon by an experienced cameraman (especially important when dealing with an anatomic region that is unfamiliar), and identification and division of the adrenal vein early in the operation when the adrenal remains attached superiorly and laterally. As shown in Figure 3 of the manuscript, when operative time is used as a measure of the learning curve, this operation can be challenging when one’s experience is modest. Importantly, the technical nuances of trocar placement, patient positioning, and the initial operative dissection, are critical to the successful performance of this operation and difficult to convey accurately even in a video. Professor Walz and the members of his Institute for Minimally Invasive Surgery at The University Clinic of Essen deserve tremendous credit for developing and perfecting a technique which allows for the safe and rapid removal of benign primary adrenal neoplasms with minimal dissection and virtually no blood loss, while affording the surgeon excellent exposure. In our modest experience with this technique at the University of Texas M.D. Anderson Cancer Center, few patients have required more than an overnight hospital stay.