Laparoscopic adrenalectomy: lateral transabdominal approach vs posterior retroperitoneal approach

Biomed & Pharmacother 2000 ; 54 Suppl 1 : 215-9 © 2000 I~ditionsscientifiqueset mrdicales Elsevier SAS. All rights reserved

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Laparoscopic adrenalectomy: lateral transabdominal approach vs posterior retroperitoneal approach K. Yoneda, E. Shiba, T. Watanabe, K. Akazawa, K. Shimazu, Y. Takamura, S. Kim, E Tsukamoto, Y. Tanji, T. Taguchi, S. Noguchi Department of Surgical Oncology, Osaka University Medical School, Osaka, Japan Summary -- Laparoscopic adrenalectomyhas been used to remove a wide variety of adrenal neoplasms.Although several laparoscopic approaches to the adrenal gland have been described,the lateral transabdominalapproach has severaladvantageswhen compared with other approaches for laparoscopic adrenalectomy.From October 1995 to July 1999, we performed laparoscopic adrenalectomieson 16 patients, including eight posterior retroperitonealapproaches and eight lateral transabdominalapproaches. Sixteen patients, ranging in age from 23 to 69 years, were treated for the following conditions: non-functioningadenoma, four patients; aldosteronoma',seven patients; pheochromocytoma, three patients; Cushing's adenoma, two patients. The average tumor size was 2.5 _+0.5 cm (1.8-3.0 cm, median 2.4 cm) in the lateral transabdominalapproach, 1.2 + 0.8 cm (0.8-3.2 cm, median 1.75 cm) in the posterior retroperitonealapproach. Average operative time of lateral transabdominalapproach was significantlyshorter than that of the posterior retroperitoneal approaches (mean 129 min vs 269 min, P = 0.0005). Conversionto laparotomywas required in one patient in the posteriorapproach. Postoperativecomplicationoccurred in one pneumothoraxin the lateral transabdominalapproach and two subcutaneousemphysemasin the posterior retroperitonealapproach. There was no statistical difference in blood loss during the operation in the two groups. There was no mortalityin either group. The lateral transabdominalapproach is a safe and efficienttechnique for the removal of the adrenal neoplasms.Compared with other approaches, this technique has a wider working space and also good exposure for removing the adrenal gland. © 2000 l~ditionsscientifiqueset mrdicales Elsevier SAS laparoscopic adrenalectomy / lateral transabdominal approach / posterior retroperitoneal approach

Conventional open surgical approaches to the adrenal gland have been rapidly replaced with laparoscopic approaches. Since first reported in laparoscopic adrenalectomy series performed by several authors in 1992 [ 1-2], many reports confirmed the advantages of laparoscopic adrenalectomy. The indications for laparoscopic adrenalectomy are essentially the same as those described for open adrenalectomy. The choice of approach depends on t u m o r size, location and adrenal pathology. Recent reviews suggest that tumor size and malignancy remain the limiting factors to laparoscopic adrenalectomy. Although various laparoscopic approaches had been described, each of these methods has specific advantages and disadvantages. The lateral transabdominal approach is easier to learn than the posterior retroperi-

Correspondence and reprints: KoriYoneda, Department of Surgical Oncology, Osaka University Medical School, 2-2-E10 Yamadaoka, Suita-City,Osaka 565-0871, Japan.

toneal approach and allows a wide working space and good exposure to access the adrenal gland. Moreover, the lateral t r a n s a b d o m i n a l a p p r o a c h has various anatomical landmarks. In this report, we reviewed 16 consecutive laparoscopic adrenalectomies performed at our institution using either the lateral transabdominal approach or posterior retroperitoneal approach. Comparison is made between the two groups, which evaluated clinical outcomes from both methods. P A T I E N T S AND M E T H O D S From October 1995 to July 1999, we performed laparoscopic adrenalectomies on 16 patients at the Department of Surgical Oncology, Osaka University Hospital. Of the 16 patients, six men and ten women ranging in age from 23 to 69 years, eight patients underwent laparoscopic a d r e n a l e c t o m i e s by the posterior r e t r o p e r i t o n e a l approaches (mean age, 58 -+ 7 years; median, 56.5 years) and eight patients underwent laparoscopic adrenalectomies

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Table I. Demographics of laparoscopic adrenalectomy patients. Lateral transabdominal approach (N = 8)

Posterior approach (N = 8)

P-value

47-69 58 _+7 56.5

23-55 47 _+ 10 49

NS

5 3

5 3

NS

2 6

1 7

NS

1.8-3 2.5 _+0.5 2.4

0.8-3.2 1.2 _ 0.8 1.75

Age (years) range mean + SD median Gender female male Side of adrenal right left Tumor si~e range mean + SD median

NS

NS = not significant. Table II. Indications for adrenalectomy. Lateral transabdominal approach (N = 8)

Posterior approach (N = 8)

2 2 2 2

2 5 t* 0

Non-functioning adenoma Aldosteronoma Pheochromocytoma Cushing's adenoma • MEN2A (multiple endocrine neoplasia type 2A)

by the lateral t r a n s a b d o m i n a l a p p r o a c h ( m e a n age, 47 + 10 years; median, 49 years). All 16 cases were nonmalignant unilateral tumors. The average tumor sizes in each group were: 2.5 + 0.5 cm (1.8-3.0 cm; median 2.4 cm) in the lateral transabdominal approach, 1.2 + 0.8 cm (0.8-3.2 cm; median 1.75 cm) in the posterior retroperitoneal approach. There was only one patient who required conversion to open procedure in the posterior retroperitoneal approach. The demographic data, location and size of the tumor in the two groups were compared between these two groups (table I). All patients had a complete preoperative endocrine evaluation. Preoperative imaging, either computed tomography (CT) scan or magnetic resonance image (MRI) scan, were also performed in order to determine the size and location of the tumor, and the relationship with surrounding organs. The preoperative diagnosis for 16 patients were nonfunctioning adenoma in four patients, aldosteronoma in seven patients, p h e o c h r o m o c y t o m a in three patients and Cushing's adenoma in two patients (table 11).

Lateral transabdominal laparoscopic adrenalectomy After induction of general anesthesia, a Foley catheter and a nasogastric tube were inserted. In case of a pheochromo-

cytoma, we placed the necessary monitoring devices, an arterial line, central venous pressure m o n i t o r and pulmonary arterial pressure monitor. The patient was placed in the lateral decubitus position. The operating table was flexed at the waist, and the kidney rest elevated. The upper arm of the patient was positioned over the chest in a sling. Four 10-mm trocars were placed in the subcostal region in the midclavicular line and in the anterior axillary, midaxillary and posterior axillary lines (figure 1A). Under an open laparoscopy method, a 10-ram trocar was placed in the anterior axillary line and the pneumoperitoneum was established with carbon dioxide gas up to a pressure of 12 m m H g . The laparoscope was inserted through this cannula into the abdominal cavity. An atraumatic grasper and a dissector were inserted through the midclavicular and midaxillary cannulas. On the left, the splenic flexure of the colon and spleen were mobilized from their retroperitoneum attachments. Incision of the retroperitoneum along the lateral side of the spleen proceeding to the level of the gastric funds, the spleen would fall medially without any retraction. To expose the adrenal gland, the harmonic scalpel was useful for dissecting tissues surrounding the gland. When the central vein was seen from the left renal vein, it was carefully

Two approaches to laparoscopic adrenalectomy

! Mid.

I

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.

~r

a~llmty

Figure 1. Site of laparoscopic adrenalectomy. A. Lateral transabdonainal approach. B. Posterior retroperitoneal approach.

dissected, clipped and divided. Then the adrenal gland was removed. On the right, the liver was detached from the triangular ligament. This maneuver allowed the right lobe of the liver to be rotated medially by a fan retractor and the right kidney was visible. The Gerota fascia was incised, and the adrenal gland was identified in the area circumscribed by the liver, inferior vena cava (IVC) and kidney. Removal of the right adrenal gland required careful dissection because of the difficulty in control of bleeding if IVC injury occurred. The central vein was then clipped and cut. The adrenal gland including the tumor was placed in a plastic bag and removed. Posterior retroperitoneal adrenalectomy

laparoscopic

The patient was placed in a lateral decubitus position with the operating table flexed at the waist. Under an open laparoscopy method, retroperitoneum space was dissected by operator's finger. Then a 'balloon' was used as a dissector to expose the retroperitoneum space, using a part of the index finger of a surgical rubber globe. We tied up the balloon with Nelaton's catheter and approximately 500 ml of saline was injected into the balloon. After dissection of the retroperitoneum space, the pneumoretroperitoneum was kept with carbon dioxide gas at 12 mmHg. Three 10-ram trocars were placed posteriorly between the costal margin and the iliac crest (figure 1B). The exposure of the adrenal gland was more difficult than the lateral transabdominal approach because of the small working space, and there were no distinct landmarks for dissecting except the kidney. When the central vein was identified, the procedure was similar to that of the lateral transabdominal approach.

RESULTS There were no statistical differences in the factors of age, gender, site of adrenal tumor and tumor size in the two groups (table I). However, site of adrenal tumor was dominantly distributed in the left side in both groups. The largest tumor size was 3.2 cm among these groups. The mean operative time for the lateral transabdominal approach was significantly shorter than that for the posterior retroperitoneal approaches, P = 0.0005 (table 111). The learning curves of both approaches were also compared (figure 2). The operative time seemed to shorten gradually, although one patient who converted to an open procedure in the posterior approaches was excluded from the data. There was no statistical difference in blood loss during the operation in the two groups. Only one patient required conversion to an open procedure in the posterior approaches because of the intraoperative hemorrhage (total amount of blood loss was 2,800 ml). Postoperative complication occurred in one pneumothorax in the lateral transabdominal approaches and two subcutaneous emphysemas in the posterior retroperitoneal approaches. All of these patients were treated with conservative therapy and recovered in a few days. The starting days of the oral intake and ambulation showed no statistical difference in the two groups. DISCUSSION Laparoscopic adrenalectomy is rapidly becoming the standard technique for surgical removal of the adrenal gland. Various reports for laparoscopic adrenalectomy

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Table III. Comparison of perioperative and postoperative parameters. Lateral transabdominal approach (N = 8)

Posterior approach (N = 8)

P-value

129 _+32 133

269 -+ 80 265

0.0005

42 _+44 30

88 _+45 50

NS

Operative time (min) mean + SD median Blood loss (mL) mean +- SD median Complication pneumothorax subcutaneous emphysema Oral intake (days) Ambulation (days)

1 2 1.3 - 0.2

1.2 _+0.1 1.2 _+0.2

NS NS

1.3 _+0.1

NS = not significant

350 300

l

250 []Lateral Operative Time

(min)

200

l transabdominal

150

C

approach ~x] P o s t e r i o r

i00

approach

50 0

I,

1

2

3

4

5

6

7

8

Case

Figure 2. Learning curve of the laparoscopic adrenalectomy.

have been described since 1992. Clinical comparison has been made between several laparoscopic approaches and an open procedure. Those reports mainly document the enhanced recovery, decreased intraoperative blood loss, shorter hospital stay and costeffectiveness [3-6]. The tumor size and malignancy remain the limiting factors to laparoscopic adrenalectomy. The maximum size of the tumors that can be removed by laparoscopic adrenalectomy varies widely. It depends on the type of the tumor as well as the experience of the surgeon. Although several retrospective trials have attempted to determine which laparoscopic approach is safer and more effective, the lateral transabdominal approach has

several distinct advantages when compared with other approaches. One of the benefits of this technique is the good exposure to access the adrenal gland. By the lateral decubitus position, the spleen or liver will be easy to mobilize by its own gravity. And also numerous landmarks are helpful to identify the adrenal gland. Disadvantages of this technique include prior intra-abdominal trauma or surgery. In the posterior retroperitoneal approach, intraabdominal adhesions from previous abdominal surgery can be avoided. But disadvantages of this technique include a small working space. It limits the size of the tumor that one can safely remove. And few landmarks make it more difficult to identify the adrenal gland. In

Two approaches to laparoscopic adrenalectomy our series, we experienced a significant difference in operative time between the two methods. Most of the time this difference in operating time is c a u s e d by spending time in dissection in order to reach the adrenal gland. In conclusion, laparoscopic adrenalectomy is b e c o m ing a standard care of the adrenal b e n i g n neoplasms. We found both the lateral and posterior approach to be safe and effective. Specific advantages and disadvantages exist in both approaches. In practice, we favor the lateral t r a n s a b d o m i n a l a p p r o a c h for u n i l a t e r a l b e n i g n tumors. It is clear that an adequate consideration with preoperative e v a l u a t i o n is i m p o r t a n t to select the approach of adrenalectomy.

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