Laparoscopic Adrenalectomy: The Initial 3 Cases

0022-5347/93/1495-0973$03.00/0 THE JOURNAL OF UROLOGY Copyright © 1983 by AMERICAN UROLOGICAL ASSOCIATION, INC.

Vol. 149,

Original Articles LAPAROSCOPIC ADRENALECTOMY: THE INITIAL 3 CASES EIJI HIGASHIHARA, YOSHINORI TANAKA, SHIGEO HORlE, SEIJI ARUGA, KIKUO NUTAHARA, SHIGERU MINOW ADA AND YOSHIO ASO From the Department of Urology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan

ABSTRACT

Laparoscopic adrenalectomy was performed on 3 patients with primary aldosteronism. Traction with 2 steel skewers placed subcutaneously over the costal arch was combined with conventional intraperitoneal carbon dioxide gas insufflation. This combination provided a good operative field at 8 mm. Hg insufflation pressure. The laparoscopic approach to the adrenal gland requires neither a large skin and muscle incision nor resection of rib(s), and offers lower morbidity and rapid convalescence. Laparoscopic adrenalectomy is a new minimally invasive operation for the treatment of adrenal adenoma. KEY WORDS:

peritoneoscopy, adrenal glands, hyperaldosteronism

There has been rapid advance in laparoscopic surgery encompassing many fields, including general surgery, gynecology and urology. In recent years laparoscopic nephrectomy,I varicocelectomy,2-4 pelvic lymphadenectoml and even prostatectomy6 have been reported in the urological literature. Advantages of this less invasive technique are obvious to the patient and include shorter hospitalization, lower morbidity, better cosmetic results and a more rapid convalescence. However, laparoscopic procedures require technical experience, anatomical knowledge and sufficient instrumentations for the surgeon. We have performed laparoscopic nephrectomy in animals as well as clinically.7 In combination with the manufacturer we have developed the instruments required for dissection of retroperitoneal tissue and organs. We have currently extended laparoscopic surgery to adrenalectomy.

titis. Primary aldosteronism with multiple adenomas 8 or unilateral idiopathic adrenal hyperplasia 9 was suspected. Bilateral idiopathic adrenal hyperplasia was less likely because of the normal right adrenal gland on CT, elevated plasma IS-hydroxycorticosterone level10 and suppressed 131iodine (131 I) -aldosterol uptake in the right adrenal gland. 11 In patients 2 and 3 primary aldosteronism was suspected by hypertension and hypokalemia, and was diagnosed by laboratory data (table 1). A left adrenal adenoma was diagnosed on CT and 131I-aldosterol adrenal scintigraphy. Laparoscopic adrenalectomy was performed after the patient was fully informed of the potential risks of laparoscopic surgery. The patient underwent preoperative bowel preparation with low fiber foods for 2 days with an overnight fast. Then, 250 m!. 13.6% magnesium citrate solution were given 1 day preoperatively. Enemas were given the night before and the morning of the operation. Preoperative antibiotics consisted of 0.5 million units polymyxin B sulfate orally every 6 hours for 2 days. A nasogastric tube and urethral catheter were placed while the patient was under general anesthesia. The patient was placed in a right semilateral position with soft cushions to

PATIENTS AND METHODS

Patient characteristics are shown in table 1. The 2 left adrenal tumors in patient 1 were incidentally detected on computerized tomography (CT) during evaluation of pancreaAccepted for publication October 9, 1992.

TABLE l. Summary of patient characteristics Pt. 1 Sex~age (yrs.) Lt. adrenal tumor: Size (mm.)

Pathology Preop./postop. laboratory data: Adrenocorticotropic hormone (pg./ml.) Cortisol (I'g./dl.) Plasma renin activity (ng./ml./hr.)* Aldosterone (pg./dl.)* 18-Hydroxycorticosterone (ng./dl.) Plasma sodium (mEq./l.) Plasma potassium (mEq./I.) Preop./postop. blood pressure (mm. Hg): Systolic Diastolic

Pt. 2

Pt. 3

Normal Laboratory Value

M~47

F~53

M~54

20 x 17 x 16 16 x 14 x 12 Hyperplasia

20 x 20 x 10

18 x 16 x 12

Adenoma

Adenoma

18/23 5.6/11.4 0.2/1.2 221.5/43 95/69 144/138 2.7/4.3

22/49 10.1/16.3 0.1/1.0 248/34 101/9.0 143/140 2.4/4.7

22/47 7.0/13.3 0.1/0.1 227/15 55/21 147/140 2.9/4.5

60 or less 5.6-21.3 0.2-2.7 180 or less 9-58 133-150 3.8-5.0

160/110 90/60

180/140 90/86

150/130 100/84

150 or less 90 or less

* Data obtained during bed rest.

973

974

HIGASHIHARA AND ASSOCIATES

0\ 0 _ Umbilicus

FIG. 1. Patient is placed in semilateral position. After creation of pneumoperitoneum 2 steel skewers are advanced subcutaneously over left costal arch. Nylon sutures are placed around skewers and attached to retractor.

FIG. 2. Phrenicocolic ligament (Zig.) is grasped and incised with grasping forceps and scissors. Peritoneal incision is extended along dotted line to reflect left colic flexure.

FIG. 3. Anterosuperior surface of renal vein (v.) is dissected to identify adrenal vein. Adrenal vein is isolated, secured with 3 or 4 ligature ' clips and incised.

975

LAPAROSCOPIC ADRENALECTOMY

FIG. 4. Left adrenal bed following laparoscopic adrenalectomy. Pancreas is reflected cephalad. Resected adrenal gland is located above upper renal pole.

FIG. 5. Adrenal gland is packed in polyethylene sac and removed through 11 mm. trocar hole.

prevent nerve and muscle injury during rotation of the operating table. A 1.5 cm. skin incision was made along the upper margin of the umbilicus and the peritoneal cavity was opened under direct vision. An 11 mm. trocar sheath was inserted into the peritoneal cavity without using a sharp-tipped pyramidal inner unit. After confirming correct placement of the trocar sheath with a laparoscope, a pneumoperitoneum was created with high flow carbon dioxide insufflation under 12 mm. Hg pressure. A zero degree 10 mm. laparoscope was used and the laparoscopic procedures were conducted with 2 sets of video monitors.12 After the pneumoperitoneum was created 2 steel skewers were advanced subcutaneously over the left costal arch, approximately 2 cm. apart and placed in parallel. Two No.2 monofilament nylon sutures were placed around each skewer and connected to the costal retractor (fig. 1). The insufflation

pressure was reset at 8 mm. Hg upon completion of the costal traction. Then, 3, 10 mm. trocar sheaths were placed under laparoscopic monitoring: 1 in the mid axillary line at the umbilical level and 2 in the mid clavicular line approximately 7 cm. above and below the umbilicus. With grasping forceps and scissors with electrocautery capability the phrenicocolic ligament was grasped and incised (fig. 2) . The peritoneal incision was extended downward to the lower pole of the kidney and several centimeters medial to the phrenicocolic ligament. The left colic flexure was reflected medially by dissecting the transverse mesocolon and the descending colon from the retroperitoneal structures. Dissecting along the anterior surface of the kidney, the renal vein was exposed and the anterosuperior portion was further dissected to visualize the left adrenal vein, which is the most important landmark. The left adrenal vein was then dissected, skeletonized, secured with 3 or 4 ligature clips and incised leaving 2 clips on the renal vein side (fig. 3). The distal end of the adrenal vein was grasped and the adrenal gland was meticulously dissected in proximity to the lateral surface of the aorta and the medial surface of the kidney. By selecting this dissection plane, the adrenal gland was removed as a whole without leaving any remnants of adrenal tissue. The left adrenal arteries, consisting of many small branches encountered during dissection, were secured with clips or electrocauterized and transected. The operative field was kept clean with half-size gauze, which was placed into the operative field with 5 mm. straight forceps through a 10 mm. trocar sheath. Care was taken not to injure the pancreas, which was reflected cephalad during adrenal dissection (figs. 3 and 4). This is best accomplished with a gauze or thick strong angle graspers. At completion of the resection, the adrenal gland was packed into a polyethylene sac inserted into an abdominal cavity via the umbilical 11 mm. trocar sheath (fig. 5) . The sac was removed through the umbilical incision together with the trocar sheath. A soft drain was inserted through the mid axillary trocar sheath with the tip placed at the previous site of the adrenal gland. The medially retracted left colic flexure was replaced in the original position and the incised parietal peritoneum was sutured with a stapler. Each of the laparoscopic sites was closed after confirming the absence of active bleeding. RESULTS

In all patients the adrenal gland was completely removed without leaving any remnant gland and an open operation was not required to complete the adrenalectomy. Operative times

~--

.......

976

HIGASHIHARA AND ASSOCIATES Indexes of morbidity and convalescence for laparoscopic adrenalectomy and posterior open adrenalectomy

TABLE 2.

No. pts. Age (yrs.) Operating time (mins.) Blood loss (mI.) Days drain indwelling Drainage vol. (mI.) Days analgesics required Days of restricted physical activity Days of restricted food intake Postop. hospital days

Laparoscopic Approach

Posterior Approach

3 ± ± ± ± ± ± ±

5 43.4 ± 14.2 192 ± 15 223 ± 46 3.8 ± 1.1 114 ± 59 3.8 ± 2.2 3.2 ± 0.8

Not significant <0.05 Not significant Not significant Not significant Not significant Not significant

3.7 ± 0.6

3.4 ± 0.6

Not significant

12.3 ± 1.5

23.2 ± 4.6

<0.01

51.3 418 220 3.3 113 4.7 3.3

3.8 122 72 2.1 75 0.6 0.6

P Value

Data are given as mean plus or minus standard deviation. All patients had a left adrenal adenoma with primary aldosteronism. The posterior approach always involved resection of the 12th rib.

were 525, 285 and 455 minutes, which included approximately 20 minutes needed to place the steel skewers for traction. Blood loss, estimated by weighing gauze, was 300, 160 and 200 gm., and transfusion was not required. Blood pressure, hormonal states and electrolytes normalized postoperatively (table 1). The main data related to the morbidity of laparoscopic adrenalectomy and convalescence after the procedure are compared with those of open adrenalectomy via the posterior approach in table 2. An increased plasma amylase level was noted in patient 2 for 3 days postoperatively. A similar postoperative increase in plasma amylase was observed in 2 of the 5 patients who underwent adrenalectomy via the posterior approach. No complications or postoperative discomfort related to the use of steel traction skewers was observed. Pathological study revealed nodular hyperplasia of the adrenal gland in patient 1 and an adrenal adenoma in patients 2 and 3. DISCUSSION

In recent years the laparoscopic frontier has been rapidly extended forward in the urological field. 12 The major beneficiary of laparoscopic surgery is the patient. Hospital stay, convalescence, morbidity and operative scarring are minimal compared to a traditional open operation. We used steel skewers for traction in combination with pneumoperitoneum. This method was initially reported for laparoscopic cholecystectomy.13 Abdominal wall traction was used independently or in combination with pneumoperitoneum. This method prevents collapse of the pneumoperitoneum during insertion or removal of graspers or gauze via the trocar sheath. The traction of the costal arch is suitable for laparoscopic adrenalectomy because traction wires do not interfere with the surgical manipulation. In our report the adenomas were located on the left side in all patients. The blood supply of the adrenals is different from side to side. Removal of the right adrenal gland may be more difficult due to the short adrenal vein on the right side. In the left adrenal gland, the main adrenal vein is long enough to secure with clips. The most important landmark for laparoscopic left adrenalectomy is identification and isolation of the left adrenal vein. The major arterial supply of the adrenal consists of many small branches derived from the aorta, renal artery and inferior phrenic artery. These branches are meticulously cauterized or clipped before they are divided. Caution must be taken to prevent unintentional cautery to contiguous structures by monopolar electrocautery. The pancreas, located close to the left adrenal, can be carefully dissected away bluntly from the periadrenal fat without using electrocautery (fig. 4). The size of the adrenal is suitable for removal through an 11 mm. laparoscopic port. While a tissue morcellator is required to remove the kidney via the laparoscopic incision in laparos-

copic nephrectomy,12 adrenal entrapment may be accomplished with a sac without tissue morcellation. The pathological finding in patient 1 was nodular hyperplasia. In primary aldosteronism the choice of therapy is based on distinguishing unilateral adenoma from bilateral adrenal hyperplasia. With a unilateral adrenal adenoma surgical removal reverses the hypokalemia and frequently cures the hypertension. In contrast, pharmacological treatment is recommended for patients with idiopathic adrenal hyperplasia because hypertension persists after surgical treatment. l1 The right adrenal was normal on CT, and hypokalemia, hypertension and hormonal disturbances were corrected after adrenalectomy in patient 1. Therefore, this case may represent unilateral adrenal hyperplasia. 9 Long-term followup is needed to evaluate for recurrence. Open adrenalectomy requires a relatively large skin and muscle incision, and even resection of rib(s). In the laparoscopic procedure the adrenal can be approached as far as its attachment to the diaphragm without visual limitations. The anatomical site, which requires a relatively large skin and muscle incision to obtain a good operative field in open surgery, is easily approached via laparoscopy. The operating time in the initial 3 patients was longer with the laparoscopic approach than with the open posterior approach but it is expected to be further shortened due to improvement of the technique and laparoscopic equipment. While the other indexes related to morbidity and convalescence were not significantly different between the 2 procedures (table 2), the postoperative hospital stay was significantly shorter after laparoscopic surgery. We believe that laparoscopic adrenalectomy offers a reliable and minimally invasive alternative to open adrenalectomy. REFERENCES

1. Clayman, R. V., Kavoussi, L. R., Soper, N. J., Dierks, S. M., Meretyk, S., Darcy, M. D., Roemer, F. D., Pingleton, E. D., Thomson, P. G. and Long, S. R.: Laparoscopic nephrectomy: initial case report. J. Urol., 146: 278, 1991. 2. Hagood, P. G., Mehan, D. J., Worischeck, J. H., Andrus, C. H. and Parra, R. 0.: Laparoscopic varicocelectomy: preliminary report of a new technique. J. Urol., 147: 73, 1992. 3. Donovan, J. F. and Winfield, H. N.: Laparoscopic varix ligation. J. Urol., 147: 77, 1992. 4. Matsuda, T., Horii, Y., Higashi, S., Oishi, K., Takeuchi, H. and Yoshida, 0.: Laparoscopic varicocelectomy: a simple technique for clip ligation of the spermatic vessels. J. Urol., 147: 636, 1992. 5. Schuessler, W. W., Vancaillie, T. G., Reich, H. and Griffith, D. P.: Transperitoneal endosurgicallymphadenectomy in patients with localized prostate cancer. J. Urol., 145: 988, 1991. 6. Schuessler, W. W.: Personal communication. 7. Higashihara, E., Kameyama, S., Tanaka, Y., Horie, S., Sayama, T., Kano, M., Asakage, Y., Nutahara, K., Minowada, S. and Aso, Y.: Laparoscopic nephrectomy: animal experiment and clinical application. Jap. J. Urol., 83: 395, 1992. 8. Vetter, H., Fischer, M., Galanski, M., Stieber, U., Tenschert, W., Baumgart, P., Winterberg, B. and Vetter, W.: Primary aldosteronism: diagnosis and noninvasive lateralization procedures. Cardiology, suppl. 1, 72: 57, 1985. 9. Dye, N. V., Litton, N. J., Varma, M. and Isley, W. L.: Unilateral adrenal hyperplasia as a cause of primary aldosteronism. South. Med. J., 82: 82, 1989. 10. Kern, D. C., Tang, K., Hanson, C. S., Brown, R. D., Painton, R., Weinberger, M. H. and Hollifield, J. W.: The prediction of anatomical morphology of primary aldosteronism using serum 18-hydroxycorticosterone levels. J. Clin. Endocr. Metab., 60: 67, 1985. 11. Young, W. F., Jr. and Klee, G. G.: Primary aldosteronism. Diagnostic evaluation. Endocr. Metab. Clin. N. Amer., 17: 367, 1988. 12. Winfield, H. N., Donovan, J. F., See, W. A., Loening, S. A. and Williams, R. D.: Urologicallaparoscopic surgery. J. Urol., 146: 941, 1991. 13. Nagai, H., Inaba, T., Kamiya, S. and Gotoh, S.: Cholecystectomy with abdominal wall traction: a new method with no requirement of pneumoperitoneum. In: Abstracts of the First Meeting of Endoscopic Surgery, Tokyo, Japan, March 2, 1991.