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Laparoscopic adrenalectomy: posterior approach
Biomed & Pharmacother 2000 ; 54 Suppl 1 : 161-3 © 2000 l~ditions scientifiques et mrdicales Elsevier SAS. All rights reserved Mini review
Laparoscopic adrenalectomy: posterior approach S. B a b a
Department of Urology, Kitasato University, School of Medicine, 1-15-1, Kitasato, Sagamihara-shL Kanagawa, Japan Summary-Adrenalectomy for benign adrenal diseases is currently performed by transperitoneal laparoscopy. The transperitoneal approach, however, invades the intraperitoneal cavity, and may cause injury to the abdominal organs. The posterior lumbar approach allows direct access to the main adrenal vascular supply before the gland is manipulated. Retroperitoneoscopic adrenalectomy by this approach is technically feasible and most effective as regard to the simplicity of vascular control. The operating time, perioperative morbidity and cost have been reduced with this approach. © 2000 t~ditions scientifiques et mrdicales Elsevier SAS adrenal adenoma / laparoscopic adrenalectomy / morbidity / pheochromocytoma / retroperitoneal approach / voice-controlled robot
Laparoscopic surgery has been performed to reduce o p e r a t i v e m o r b i d i t y c o m p a r e d to c o n v e n t i o n a l surgery. This procedure, however, allows a more precise operative procedure, by providing better visualization of the operative field. For an operation like adrenalectomy, which causes considerable operative morbidity to dissect the gland residing near the center of the body, a laparoscopic approach can be considered to be useful. Since 1992 [4], four different approaches have been described for laparoscopic and r e t r o p e r i t o n e o s c o p i c a d r e n a l e c t o m y : 1) transperitoneal anterior a p p r o a c h [5, 8]; 2) transperitoneal lateral a p p r o a c h [3, 4]; 3) e x t r a p e r i t o n e a l flank approach [10]: and 4) extraperitoneal posterior lumbar approach [1]. Each approach has its own advantages and drawbacks, requiring different positioning of the patient, varying from a semilateral to a prone position. The posterior lumbar approach to the adrenal gland is probably the simplest method among the various laparoscopic or retroperitoneoscopic approaches. As in open surgery, the advantages o f the posterior lumbar approach include the rapidity o f the procedure, earlier access and control o f the adrenal vessels. The operation can be done retroperitoneally, entering neither the thorax nor the p e r i t o n e a l cavity. The technical principles o f this approach are described and our c l i n i c a l r e s u l t s o f r e t r o p e r i t o n e o s c o p i c adrenalectomy by the posterior lumbar approach are discussed.
SUBJECTS AND M E T H O D S Between March 1996 and December 1999, 30 patients with adrenal diseases were operated laparoscopically by the posterior lumbar approach (table I). The indications for laparoscopic adrenalectomy, in general, include functioning adrenal cortical adenomas, pheochromocytomas with wellcontrolled hypertension, endocrine inactive tumors such as a cortical adenoma, adrenal cyst and myelolipoma that are increasing in size or causing local symptoms. The patient, under general intubated anesthesia, is placed in the prone position, with the lumbar area flexed on a jackknife table to provide access to the subcostal space. Three trocars are used: 12-mm trocar 3 cm below the tip of the twelfth rib for the scope, 12-mm trocar 3 cm below the twelfth rib on the lateral margin of the sacrospinalis Table I. Laparoscopic adrenalectomy: the posterior approach (March 1996-December 1999).
Subjects Number of patients Age (mean _+S.D.) Tumor size range Pathology aldosteronoma Cushing's syndrome pheochromocytoma myelolipoma non-active tumor
30; female:male = 16:14 45.9 _+10.3 years 10--55 mm 18 8 2 1 1
162s
S. Baba
+ Figure 1. Port sites and position of the surgical team. The assistant can be replaced with a robot. muscle and 5-mm trocar on the posterior axillary line in the eleventh intercostal space (figure 1). If retraction of the kidney is necessary, another 5-mm port is made on the posterior axillary line above the iliac crest. Care must be taken to avoid possible injury to the subcostal nerve, vessels and the medial crus of the diaphragm. The pneumoretroperitoneum is started under the maximum pressure of 10 mmHg. The main steps of the operation [1] are as follows: A 'retroperitoneal working space' has to be created between the posterior aspect of the Gerota's fascia and the psoas muscle, according to the method described by Gaur [7]. The working space should be created outside the Gerota's fascia in the posterior pararenal fossa to avoid the perinephric adipose tissue migrating into the operative field. The medial side of the Gerota's fascia is incised along the diaphragmatic crus, and then transversely over the adrenal. The middle adrenal arteries arising from the aorta are identified in the relatively superficial layer of dissection. The renal pedicle is identified. On the right side, the vena cava can be easily identified below the level of adrenal arteries along the medial crus of the diaphragm (figure 2). Because the right adrenal vein is retrocaval, it is easily dissected from the dorsal side. Once the central vein is secured and transected, the lower aspect of the adrenal gland is dissected from the craniomedial surface of the ipsilateral kidney. The Gerota's fascia on the renal margin has to be transversely incised at this phase to identify the lateral margin of the adrenal gland. The
Figure 2. Anatomicallandmarksfor the posterior approach on the right side. (M.C.D.: medialcrus of the diaphragm;V.C.I.: venacava inferior). posterior adrenal vessels from the renal pedicle are secured and transected, and the lateral margin of the adrenal is followed upwards to reach the superior adrenal artery and vein that are clipped or cauterized. The ventral aspect of the gland is further dissected from the parietal peritoneum that lies beneath the ventral side of the gland. The adrenal gland is, thus, freed with the posterior leaf of the Gerota's fascia and peri-adrenal fat tissue attached to the gland. If the adrenal gland is larger than 3 cm in diameter, the camera port should be changed to the most medially placed trocar, to evacuate the gland through the primary open incisional wound that is relatively more spacious than the other punctured port sites. RESULTS
Table H summarizes the procedure time of retroperitoneoscopic adrenalectomy by the posterior lumbar approach. Visualization of the adrenal vessels in the early phase of the procedure afforded localizing clues for the adrenal gland. The history of the upper abdominal surgery in three patients or lower abdominal surgery in eight patients caused no problem for the adrenalecTable IIo Laparoscopic adrenalectomy by the retroperitoneal approach: procedure time and number of cases.
Year
~me(min)
Number
Left
Right
1996 1997 1998 1999
142 143 159 140
13 9 5 3
9 6 2 1
4 3 3 2
Laparoscopic adrenalectomy: posterior approach tomy by the posterior lumbar approach. The number of trocars required for the posterior lumbar approach averaged only 3.1, which was significantly less than that required for the transperitoneal approach in our hands (4.1, P < 0.02). The amount of blood loss by the posterior l u m b a r approach averaged 45 + 66 mL (mean + S.D.). All patients except four who complained of pain were ambulated on the first postoperative day. There were no significant differences in painkiller doses, nor in the duration of the hospital stay between patients undergoing laparoscopic adrenalectomy by the transperitoneal and retroperitoneal approaches. In one patient, pneumothorax tension developed due to inadvertent injury to the medial crus of the diaphragm by trocar insertion, and had to be converted. DISCUSSION Laparoscopic adrenalectomy by the posterior lumbar approach was developed in our department in order to avoid the unnecessary intraperitoneal invasion, and to decrease procedure time to the level of open surgery. This new approach had to satisfy various criteria: feasibility, efficacy and cost. As far as feasibility as assessed in terms of operative morbidity is concerned, there was no mortality in this series, nor in the series by extraperitoneal flank approach, reported by others [6, 9]. The operating time is currently an average of 144 minutes, which is comparable to open surgery. The surgical conversion early in this series can be explained by lack of experience, as this conversion rate (1/30) has regularly deceased to none in the latest series. The main advantage of the posterior lumbar approach is to gain direct access to the adrenal hilar vessels without the necessity of retracting any organs or manipulating the fragile adrenal gland. Once having been identified, these vessels can become the most reliable anatomical landmark to the adrenal gland. Furthermore, the history of intraperitoneal surgery is not a problem for retroperitoneoscopic adrenalectomy, and full bowel preparation is not required, resulting in shorter and less invasive preoperative management. C o m p a r e d to the results o f transperitoneal laparoscopic adrenalectomy in the literature [3-5, 8], the morbidity of laparoscopic adrenalectomy by the posterior approach appears to be very low, taking into account the technical difficulty of this approach. The learning curve in our experience appears to represent about 20 patients per operator. As for efficacy, there is no difference in quality o f resection
163s
between open and laparoscopic adrenalectomy by the posterior approach. Despite the technical simplicity, there are factors such as limited working space and paucity o f familiar anatomical landmarks that may defy the attempt to localize the adrenal gland and cause inadvertent injury of major vessels. Other disadvantages of this approach include the required prone jackknife position, relatively small skin area for trocar positioning, and possible injury of the diaphragm in the vicinity, resulting in tension pneumothorax. But these disadvantages are outweighed by the advantages of this procedure in most patients with adrenal tumors that are usually smaller than 5 cm in diameter. Although the instrument necessitated in this procedure is still expensive, the marked reduction of the hospital stay, and the reduction of the transfusion and drug prescription rates can explain the decrease of the total cost of laparoscopic surgery. Another important fact is that this procedure, with the use of a voice-controlled robot, is now routinely performed with only two persons of the surgical team: the surgeon and only one rotating nurse [2].
REFERENCES 1 Baba S, Miyajima A, Uchida A, Asanuma H, Miyakawa A, Murai M. A posterior lumbar approach for retroperitoneoscopic adrenalectomy: assessment of surgical efficacy. Urol 1997 ; 50 : 19-24. 2 Baba S, Ito K, Yanaihara H, Nagata H, Murai M, Iwamura M. Retroperitoneoscopic adrenalectomy by a lumbodorsal approach: clinical experience with solo-surgery. World J Urol 1999 ; 17 : 54-8. 3 Fletcher DR, Beiles CB, Hardy KJ. Laparoscopic adrenalectomy. Aust NZ J Surg 1994 ; 64 : 427-30. 4 Gagner M, Lacroix A, Prinz RA, Bolte E, Albala D, Potvin C, et al. Early experience with laparoscopic approach for adrenalectomy. Surgery 1993 ; 114 : 1120-4. 5 Go H. Laparoscopic adrenalectomy. Jap J Urol 1993 ; 84 : 1675-80. 6 Gasman D, Droupy S, Koutani A, Salomon P, Antiphon P, Chassagnon J, et al. Laparoscopic adrenalectomy: the retroperitoneal approach. J Urol 1998 ; 159 : 1816-20. 7 Gaur DD. Laparoscopic operative retroperitoneoscopy; use of a new device. J Urol 1992 ; 148 : 1137-9. 8 Higashihara E, Tanaka Y, Horie S, Aruga S, Nutahara K, Minowada S, et al. Laparoscopic adrenalectomy: the initial 3 cases. J Urol 1993 ; 149 : 973-6. 9 Miyake O, Yoshimura K, Yoshioka T, Honda M, Kokado Y, Miki T, et al. Laparoscopic adrenalectomy: comparison of the transperitoneal and retroperitoneal approach. Eur Urol 1998 ; 33 : 303-7. 10 Whittle DE, Schroeder D, Purchas SH, Sivakumaran P, Conaglen JV. Laparoscopic retroperitoneal left adrenalectomy in a patient with Cushing's syndrome. Aust NZ J Surg 1994 ; 64 : 375-6.
Laparoscopic adrenalectomy: posterior approach S. B a b a
Department of Urology, Kitasato University, School of Medicine, 1-15-1, Kitasato, Sagamihara-shL Kanagawa, Japan Summary-Adrenalectomy for benign adrenal diseases is currently performed by transperitoneal laparoscopy. The transperitoneal approach, however, invades the intraperitoneal cavity, and may cause injury to the abdominal organs. The posterior lumbar approach allows direct access to the main adrenal vascular supply before the gland is manipulated. Retroperitoneoscopic adrenalectomy by this approach is technically feasible and most effective as regard to the simplicity of vascular control. The operating time, perioperative morbidity and cost have been reduced with this approach. © 2000 t~ditions scientifiques et mrdicales Elsevier SAS adrenal adenoma / laparoscopic adrenalectomy / morbidity / pheochromocytoma / retroperitoneal approach / voice-controlled robot
Laparoscopic surgery has been performed to reduce o p e r a t i v e m o r b i d i t y c o m p a r e d to c o n v e n t i o n a l surgery. This procedure, however, allows a more precise operative procedure, by providing better visualization of the operative field. For an operation like adrenalectomy, which causes considerable operative morbidity to dissect the gland residing near the center of the body, a laparoscopic approach can be considered to be useful. Since 1992 [4], four different approaches have been described for laparoscopic and r e t r o p e r i t o n e o s c o p i c a d r e n a l e c t o m y : 1) transperitoneal anterior a p p r o a c h [5, 8]; 2) transperitoneal lateral a p p r o a c h [3, 4]; 3) e x t r a p e r i t o n e a l flank approach [10]: and 4) extraperitoneal posterior lumbar approach [1]. Each approach has its own advantages and drawbacks, requiring different positioning of the patient, varying from a semilateral to a prone position. The posterior lumbar approach to the adrenal gland is probably the simplest method among the various laparoscopic or retroperitoneoscopic approaches. As in open surgery, the advantages o f the posterior lumbar approach include the rapidity o f the procedure, earlier access and control o f the adrenal vessels. The operation can be done retroperitoneally, entering neither the thorax nor the p e r i t o n e a l cavity. The technical principles o f this approach are described and our c l i n i c a l r e s u l t s o f r e t r o p e r i t o n e o s c o p i c adrenalectomy by the posterior lumbar approach are discussed.
SUBJECTS AND M E T H O D S Between March 1996 and December 1999, 30 patients with adrenal diseases were operated laparoscopically by the posterior lumbar approach (table I). The indications for laparoscopic adrenalectomy, in general, include functioning adrenal cortical adenomas, pheochromocytomas with wellcontrolled hypertension, endocrine inactive tumors such as a cortical adenoma, adrenal cyst and myelolipoma that are increasing in size or causing local symptoms. The patient, under general intubated anesthesia, is placed in the prone position, with the lumbar area flexed on a jackknife table to provide access to the subcostal space. Three trocars are used: 12-mm trocar 3 cm below the tip of the twelfth rib for the scope, 12-mm trocar 3 cm below the twelfth rib on the lateral margin of the sacrospinalis Table I. Laparoscopic adrenalectomy: the posterior approach (March 1996-December 1999).
Subjects Number of patients Age (mean _+S.D.) Tumor size range Pathology aldosteronoma Cushing's syndrome pheochromocytoma myelolipoma non-active tumor
30; female:male = 16:14 45.9 _+10.3 years 10--55 mm 18 8 2 1 1
162s
S. Baba
+ Figure 1. Port sites and position of the surgical team. The assistant can be replaced with a robot. muscle and 5-mm trocar on the posterior axillary line in the eleventh intercostal space (figure 1). If retraction of the kidney is necessary, another 5-mm port is made on the posterior axillary line above the iliac crest. Care must be taken to avoid possible injury to the subcostal nerve, vessels and the medial crus of the diaphragm. The pneumoretroperitoneum is started under the maximum pressure of 10 mmHg. The main steps of the operation [1] are as follows: A 'retroperitoneal working space' has to be created between the posterior aspect of the Gerota's fascia and the psoas muscle, according to the method described by Gaur [7]. The working space should be created outside the Gerota's fascia in the posterior pararenal fossa to avoid the perinephric adipose tissue migrating into the operative field. The medial side of the Gerota's fascia is incised along the diaphragmatic crus, and then transversely over the adrenal. The middle adrenal arteries arising from the aorta are identified in the relatively superficial layer of dissection. The renal pedicle is identified. On the right side, the vena cava can be easily identified below the level of adrenal arteries along the medial crus of the diaphragm (figure 2). Because the right adrenal vein is retrocaval, it is easily dissected from the dorsal side. Once the central vein is secured and transected, the lower aspect of the adrenal gland is dissected from the craniomedial surface of the ipsilateral kidney. The Gerota's fascia on the renal margin has to be transversely incised at this phase to identify the lateral margin of the adrenal gland. The
Figure 2. Anatomicallandmarksfor the posterior approach on the right side. (M.C.D.: medialcrus of the diaphragm;V.C.I.: venacava inferior). posterior adrenal vessels from the renal pedicle are secured and transected, and the lateral margin of the adrenal is followed upwards to reach the superior adrenal artery and vein that are clipped or cauterized. The ventral aspect of the gland is further dissected from the parietal peritoneum that lies beneath the ventral side of the gland. The adrenal gland is, thus, freed with the posterior leaf of the Gerota's fascia and peri-adrenal fat tissue attached to the gland. If the adrenal gland is larger than 3 cm in diameter, the camera port should be changed to the most medially placed trocar, to evacuate the gland through the primary open incisional wound that is relatively more spacious than the other punctured port sites. RESULTS
Table H summarizes the procedure time of retroperitoneoscopic adrenalectomy by the posterior lumbar approach. Visualization of the adrenal vessels in the early phase of the procedure afforded localizing clues for the adrenal gland. The history of the upper abdominal surgery in three patients or lower abdominal surgery in eight patients caused no problem for the adrenalecTable IIo Laparoscopic adrenalectomy by the retroperitoneal approach: procedure time and number of cases.
Year
~me(min)
Number
Left
Right
1996 1997 1998 1999
142 143 159 140
13 9 5 3
9 6 2 1
4 3 3 2
Laparoscopic adrenalectomy: posterior approach tomy by the posterior lumbar approach. The number of trocars required for the posterior lumbar approach averaged only 3.1, which was significantly less than that required for the transperitoneal approach in our hands (4.1, P < 0.02). The amount of blood loss by the posterior l u m b a r approach averaged 45 + 66 mL (mean + S.D.). All patients except four who complained of pain were ambulated on the first postoperative day. There were no significant differences in painkiller doses, nor in the duration of the hospital stay between patients undergoing laparoscopic adrenalectomy by the transperitoneal and retroperitoneal approaches. In one patient, pneumothorax tension developed due to inadvertent injury to the medial crus of the diaphragm by trocar insertion, and had to be converted. DISCUSSION Laparoscopic adrenalectomy by the posterior lumbar approach was developed in our department in order to avoid the unnecessary intraperitoneal invasion, and to decrease procedure time to the level of open surgery. This new approach had to satisfy various criteria: feasibility, efficacy and cost. As far as feasibility as assessed in terms of operative morbidity is concerned, there was no mortality in this series, nor in the series by extraperitoneal flank approach, reported by others [6, 9]. The operating time is currently an average of 144 minutes, which is comparable to open surgery. The surgical conversion early in this series can be explained by lack of experience, as this conversion rate (1/30) has regularly deceased to none in the latest series. The main advantage of the posterior lumbar approach is to gain direct access to the adrenal hilar vessels without the necessity of retracting any organs or manipulating the fragile adrenal gland. Once having been identified, these vessels can become the most reliable anatomical landmark to the adrenal gland. Furthermore, the history of intraperitoneal surgery is not a problem for retroperitoneoscopic adrenalectomy, and full bowel preparation is not required, resulting in shorter and less invasive preoperative management. C o m p a r e d to the results o f transperitoneal laparoscopic adrenalectomy in the literature [3-5, 8], the morbidity of laparoscopic adrenalectomy by the posterior approach appears to be very low, taking into account the technical difficulty of this approach. The learning curve in our experience appears to represent about 20 patients per operator. As for efficacy, there is no difference in quality o f resection
163s
between open and laparoscopic adrenalectomy by the posterior approach. Despite the technical simplicity, there are factors such as limited working space and paucity o f familiar anatomical landmarks that may defy the attempt to localize the adrenal gland and cause inadvertent injury of major vessels. Other disadvantages of this approach include the required prone jackknife position, relatively small skin area for trocar positioning, and possible injury of the diaphragm in the vicinity, resulting in tension pneumothorax. But these disadvantages are outweighed by the advantages of this procedure in most patients with adrenal tumors that are usually smaller than 5 cm in diameter. Although the instrument necessitated in this procedure is still expensive, the marked reduction of the hospital stay, and the reduction of the transfusion and drug prescription rates can explain the decrease of the total cost of laparoscopic surgery. Another important fact is that this procedure, with the use of a voice-controlled robot, is now routinely performed with only two persons of the surgical team: the surgeon and only one rotating nurse [2].
REFERENCES 1 Baba S, Miyajima A, Uchida A, Asanuma H, Miyakawa A, Murai M. A posterior lumbar approach for retroperitoneoscopic adrenalectomy: assessment of surgical efficacy. Urol 1997 ; 50 : 19-24. 2 Baba S, Ito K, Yanaihara H, Nagata H, Murai M, Iwamura M. Retroperitoneoscopic adrenalectomy by a lumbodorsal approach: clinical experience with solo-surgery. World J Urol 1999 ; 17 : 54-8. 3 Fletcher DR, Beiles CB, Hardy KJ. Laparoscopic adrenalectomy. Aust NZ J Surg 1994 ; 64 : 427-30. 4 Gagner M, Lacroix A, Prinz RA, Bolte E, Albala D, Potvin C, et al. Early experience with laparoscopic approach for adrenalectomy. Surgery 1993 ; 114 : 1120-4. 5 Go H. Laparoscopic adrenalectomy. Jap J Urol 1993 ; 84 : 1675-80. 6 Gasman D, Droupy S, Koutani A, Salomon P, Antiphon P, Chassagnon J, et al. Laparoscopic adrenalectomy: the retroperitoneal approach. J Urol 1998 ; 159 : 1816-20. 7 Gaur DD. Laparoscopic operative retroperitoneoscopy; use of a new device. J Urol 1992 ; 148 : 1137-9. 8 Higashihara E, Tanaka Y, Horie S, Aruga S, Nutahara K, Minowada S, et al. Laparoscopic adrenalectomy: the initial 3 cases. J Urol 1993 ; 149 : 973-6. 9 Miyake O, Yoshimura K, Yoshioka T, Honda M, Kokado Y, Miki T, et al. Laparoscopic adrenalectomy: comparison of the transperitoneal and retroperitoneal approach. Eur Urol 1998 ; 33 : 303-7. 10 Whittle DE, Schroeder D, Purchas SH, Sivakumaran P, Conaglen JV. Laparoscopic retroperitoneal left adrenalectomy in a patient with Cushing's syndrome. Aust NZ J Surg 1994 ; 64 : 375-6.