LAPAROSCOPIC ADRENALECTOMY: THE RETROPERITONEAL APPROACH

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W A R O S C O P I C ADRENALECTOMY: THE RETROPERITONEAL APPROACH D. GASMAN, S. DROUPY,A. KOUTANI, L. SALOMON, P. ANTIPHON, J. CHASSAGNON, D.K. CHOPIN AND C.C. ABBOU From the Service d'llmlogie, Hbpital Henri Mondor, Cdteil, France

ABSTRACT

Purpose: Retroperitoneal laparoscopy, by providing direct access to the retroperitoneal cavity, is an interesting approach to urological surgery. We report our initial experience with retroperitoneal laparoscopic adrenalectomy. Materials and Methods: Between January 1995 and April 1997, 23 adrenalectomies were performed by retroperitoneal laparoscopy in 10 men and 12 women. The patients were placed in the lateral decubitus position and 5 trocars were used. The retroperitoneal working space was created by digital dissection and was completed by insufflation without balloon dissection. The surgical indications were Conn's adenoma in 12 cases, Cushing's adenoma in 4,bilateral adrenal hyperplasia (Cushing's disease) in 1 (treated in a single procedure), a nonfunctioning adenoma in 2, pheochromocytoma in 2 and adrenal metastasis in 1. Results: We removed 7 right and 16 left adrenal glands in an average operating time of 97 minutes (range 45 to 160).Average tumor size was 26 mm. (range 10 to 40).Average hospital stay was 3.3 days (range 1 to 10).Blood loss was minimal. Postoperative analgesic requirements were moderate. Conversion to open surgery was not necessary. The morbidity rate was low, with 1 postoperative hematoma and 1 case of persistent fever (greater than 38.50. Conclusions: Retroperitoneal adrenalectomy is a reliable and effective technique. At our institution retroperitoneal laparoscopy is now the standard adrenal surgery procedure for tumors less than 5 cm. KEY WORDS:laparoscopy, retroperitoneal space, adrenalectomy, adrenal glands Several approaches are used for adrenal surgery because of the anatomical position of the adrenal glands and the variable size of lesions affecting them. Anterior approaches permit complete investigation of the abdominal cavity, primary dissection of the vessels and removal of large lesions. However, they cause major wounds t o the abdominal wall and do not avoid the problem posed by abdominal organs. The posterolateral approach (11th or 12th rib) is the most conventional as it provides more direct access to the adrenals. However, it does not permit primary control of the vascular pedicle or bilateral adrenalectomy. The posterior approach was first described in 1936 by Y0ung.l It was initially vertical but the horizontal approach was later developed (with or without costal resection). It permits primary control of the vascular pedicle and bilateral adrenalectomy, and overcomes the difficulties posed by the abdominal viscera. Its disadvantages are frequent postoperative intercostal pain and the narrow wall opening. The search for a minimally invasive technique for the removal of these lesions, which are often small and discovered fortuitously, has led to the application of laparoscopy to adrenal surgery. The transperitoneal approach was used first and is still the most popular.2 Retroperitoneal laparoscopy was further developed in 1992 by Gaur.3 Few series of adrenalectomy by retroperitoneal laparoscopy have been published. We have performed 23 retroperitoneal adrenalectomies since January 1995. We analyze our results and published data on transperitoneal laparoscopy and the open posterior approach. Accepted for publication November 26, 1997.

MATERIALS AND METHODS

From January 1995 to April 1997 we treated 23 adrenals (22 patients) with retroperitoneal laparoscopy, and 1case of bilateral adrenalectomy was treated in a single procedure. The lesions were on the right side in 7 cases and on the lefk side in 16. The indications for surgery were Conn's adenoma in 12 cases, Cushing's adenoma in 4, bilateral adrenal hyperplasia (Cushing's disease) in 1(operated on in a single session), a nonsecretory adenoma in 2, pheochromocytoma in 2 and adrenal metastasis in 1. Tumors greater than 5 cm. in diameter and previous lumbar incision were contraindications to retroperitoneal laparoscopy. Such patients usually underwent open surgery, especially if the tumor appeared to be malignant. TECHNIQUE

Surgery was done with the patient under general anesthesia. Patients were ventilated with a mixture of air, oxygen and isoflurane. The end tidal carbon dioxide was adjusted by varying the tidal volume and respiratory frequency. Patients were placed in the lateral decubitus position. A Foley catheter and nasogastric tube were inserted preoperatively. We used traditional video celioscopy equipment with a 0-degree lens laparoscope and 5 trocars, of which 1was 12 mm., 2 were 10 mm. and 2 were 5 mm. A 15 mm. incision was made under the 12th rib. The retroperitoneum was entered by blunt dissection. The index finger was used to push the peritoneum forward, allowing the other trocars to be inserted under digital control (see figure). A 10 mm. trocar (for the laparoscope) was placed on the middle axillary line above the iliac crest, a 10 mm. trocar (triangular grasping forceps) and a 5 mm. trocar (simple grasping forceps) were placed, respectively, on the upper and lower anterior axillary line. An

1816

LAPAROSCOPIC ADRENALECTOMY

1817

Patient positionin and placement of 5 trocars (0 12 mm. trocar; 0 10 mm. trocar;0 5 mm. trocar). Axillary lines are anterior (A), middle

(Mand posterior (P?.

additional 5 mm. trocar (rotating tip coagulating scissors) was placed under the initial incision on the posterior axillary line. The 12 mm. trocar (suction irrigating device) was inserted in the initial incision. The finger was only used to push the peritoneum aside, as extensive digital dissection of the retroperitoneum would have been hazardous and hemorrhagic. The kidney remained in contact with its peritoneal attachments. Only the posterior face was dissected to identify the psoas muscle which was the first anatomical landmark. The kidney was pushed forward by the assistant using the 2 grasping forceps. The renal pedicle (often identified by arterial pulses) was dissected with the coagulating scissors and the suction device was used as a retractor. The renal artery and vein were then isolated. To the right side the vena cava was identified, allowing the dissection to be continued upwards until the adrenal vein was located, clipped and cut. To the left side the dissection of the renal pedicle, especially the renal vein, allowed us to distinguish the adrenal vein which was clipped and cut. At this stage the adrenal was generally well identified. It was then reclined in a caudal position and freed of its upper diaphragmatic attachments. The adrenal was separated from the lower pole of the kidney and peritoneum. The surgical specimen was extracted within an endoscopic bag through the 12 mm. opening. A suction drain was inserted for 24 TABLE1. Results

of

(em.)

2;)

-34 -51 -39 -49 -51 -42 -62 -34 -62 -41 -47 -50

175 175 173 165 163 158 165 157 155 170 159 153

73 70 63 65 65 67 70 69 65 62 59 68

Cushing's adenoma

-M -52 -F -47

170 172 169 172 165 168 166 155

84

Conn's adenoma Conn's adenoma COM'S adenoma Conn's adenoma Cushing's adenoma Conn's adenoma Nonfunctional adenoma Pheochromocytoma

R.- Sex - Age

Size

No.

Indication for surgery

hours. The puncture site was closed using 2-zero polyglycolic acid sutures. The operating time was defined by the time of insufflation. RESULTS

Mean patient age was 49.6 years (range 34 to 62), and there were 10 men and 12 women (table 1). Mean body weight was 69.5 kg. (range 59 to 90)and mean height was 164.6 cm. (range 153 to 175).Mean diameter of the excised lesions was 26 mm. (range 10 to 40),mean operating time was 97 minutes (range 45 to 160),mean hospital stay was 3.3 days (range 1 to 10)and mean blood loss was 70 ml. (range 0 to 450). Conversion to open surgery was not necessary. Carbon dioxide insufflation was always well tolerated due to adapted ventilatory support. The end tidal carbon dioxide was maintained between 31 and 43 mm.Hg (average 38)as the tidal volume increased from an average of 600 to 656 ml. during surgery, and the average respiratory frequency varied from 12 to 15 breaths per minute. No major complications occurred. A postoperative hematoma in the area of retroperitoneal detachment was evacuated through the orifice of the main trocar. In 1 patient fever developed (greater than 38.5C), which lasted for 48 hours. Postoperative analgesia consisted of an average dose of 2.7 gm. (range 1 to 6) of

retroperitoneal laparoscopic adrenalectomy Side

Operative Time (mins.)

Lt. Lt. Rt. Lt . Lt. Lt. Lt. Lt. Lt. Rt. Rt. Rt. Lt. Lt. Lt. Rt. Rt. Lt. Lt. Lt. Rt.

90 55 90 45 140 85 75 90 55 130 115 135 85 120 90 130 80 160 70 90 120

Analgesia Hospital A c e m o p h e n Morphine sulfate stay (p.) Equivalent (mg.) (days)

Complications

~~

1 2 3 4 5 6 7 8 9 10

-M

11

-M

-F -M

-F -M -F

-F -F -F -M

12*-F 13 14 15 16 17 18 19 20

-M

-M -M

-F -F

-F

-46 -56 -64 -40 -66 -43

85 76 68 90 66 72

60

COM'S adenoma Conn's adenoma COM'Sadenoma Nonfunctional adenoma Conn's adenoma Cushing's adenoma COM'Sadenoma Cushing's adenoma Pheochromocytoma COM'S adenoma Cushing's disease

Metastasis 170 71 21 -M -69 160 63 Conn'sadenoma 22 -F --46 164.66 69.62 Mean 49.61 * Bilateral adrenalectomyon the same patient.

Lt.

Lt.

120 60 96.96

3 3 3 3 3 3 3 3 6 2 1 1 2 2 4 2 2 3 2 3 2 2 4 2.70

0

30 30 30 30 0 0

0 20 20 10 10 0 0 0

0 0

5 5 0 0

10 20 9.57

2 2 10 4 4 2 2 3 3 4 4 4 5 5 4 3.35

None None None None None None None None None None Postop. hematoma None None None None None None None None None Fever greater than 38.X None None

1818

LAPAROSCOPIC ADRENALECTOMY

acetaminophen and 9.5 mg. of morphine sulfate equivalent (range 0 to 30). The doses were adapted according to patient tolerance using a visual analog scale. DISCUSSION

The concept of retroperitoneal laparoscopy is attractive but requires sound experience in laparoscopic surgery, which is crucial to avoid excessive morbidity. The space created by digital dissection was large enough to insert the trocars. Initially the trocars were introduced with endoscopic guidance4but they are now inserted with digital guidance as first described by Gill et al,5 which is easier because of the proximity of the trocars to each other. The working space is then completed by insufflation and the retroperitoneal elements are dissected under endoscopic guidance. We used balloon dilation for the first retroperitoneal laparoscopies (simple nephrectomy and renal cyst excision), which provided good working space but without control of the retroperitoneal dissection. We decided to remove only lesions 5 cm. or less to avoid an increase in morbidity early in our experience. Beyond this size the dissection could be complicated as the vascular pedicle is often included in the tumor but, as described with the transperitoneal approach, larger tumors should in theory be removed by the retroperitoneal approach. Primary ligature of the adrenal vein is a principle that applies to conventional surgery as well as to retroperitoneal laparoscopy. It makes it possible to excise pheochromocytomas, provided they are small and patient general status is adequate (no history of coronary heart disease or atherosclerosis). Bilateral surgery can be done during a single procedure. One of our patients was treated for bilateral adrenal hyperplasia with a total operating time of 250 minutes, including 30 minutes for repositioning. Carbon dioxide absorption is higher during retroperitoneal laparoscopy.6-7 The consequences of hypercapnia are generally well controlled by ventilatory assistance. No complica-

tions of hypercapnia occurred in this series. Subcutaneous emphysema resolved rapidly and had no consequences. Contrary to Heintz et al,*we never had to convert to open surgery because of peritoneal opening. Retroperitoneal or transperitoneal laparoscopy (tables 2 and 3 9-16) perfects the principle of minimally invasive surgery, a concept initiated with the posterior approach (table 4 17-19) which is a reference for small adrenak20 It is particularly indicated for hyperaldosteronism, as it allows less traumatic excision with a low morbidity rate and a short hospital stay. It is also perfectly adapted to surgery of hyperadrenocorticism, as it lessens surgical trauma and decreases the risk of wound complications. The operating time, which used to be the main handicap of this technique, is also becoming more acceptable. The operating time was longer in our last few patients owing to the difficult dissection in these cases of metastasis and Cushing's disease. In the 2 cases of pheochromocytoma the operating times were 140 and 120 minutes, respectively, which is explained by tumor hypervascularization and the need to secure all the vessels before mobilizing the gland. The operating time was shorter on the left (95minutes) than on the right side (114minutes). This difference was not statistically significant but the adrenal vein is often easier to locate on the left side because of its length and its termination in the renal vein which is easily identified. While laparoscopy is a good alternative to the posterior approach, the retroperitoneal approach still needs to be compared with the transperitoneal approach. Published series suggest that retroperitoneoscopy is more rapid than the transperitoneal approach, with mean operating times of 97 to 248 minutes and 170 to 270 minutes, respectively. The morbidity rate is similar or lower according to the series. The rate of conversion to open surgery is similar regardless of the technique. However, these results must be interpreted with caution given the limited number of retroperitoneoscopic series but they can be explained by the direct access to the

TABLE2. Review of the literature on retroperitoneal laparoscopic adrenalectomy References

No.

Indication for Surgery (No. pts.)

Size (mm.)

Operative

Time

(mins.)

Blood Loss (ml.)

No. Conversion to Open Surgery (%I

37

170

100

1(14)

Pneumothorax ( 1)

4.8

36

150

Not available

0

None

3

Not available

248

151

1*

Pancreatic injury (1)

41.5

180

170

3 (16)

Pneumothorax (1)

5

26

97

70

0

Hematoma (l),fever greater than 3 8 3 2 (1)

3.3

Mean 35 Three cases of conversion to transperitoneal laparoscopy.

169

122

pts.

Mandressi et a19

7

Mercan et all0

11

Takeda et all'

11

Heintz et als

18

Present series

23

Cushing's syndrome (1). pheochromoeytoma (l),aldosteronoma (11, nonfunctioning adenoma (2). adrenal wst (1) Cushing's disease (3). adrenal cyst (l),aldosteronoma (3). nonfunctioning adenoma (1). bilat. macronodular hyperplasia (1). bilat. adrenalectomy (3) Cushing's syndrome (6), aldosteronoma (5) Cushing's adenoma (5). Cushing's disease (2). aldostemnoma (2). nonfunctioning adenoma (6). pheochmmocytoma (3), bilat. adrenalectomy (2) Cushing's adenoma (4). aldosteronoma (12). nonfunctional adenoma (21, Cushing's disease ( l ) ,pheochmmocytoma (2). metastasis (1).bilat. adrenalectomy (1)

Operative Morbidity (No. pts.)

Hospital Stay (days)

Not available

4

1819

LAF'AROSCOPIC ADRENALECTOMY TABLE3. Review of the literature on transperitoneal LaDaroscoDic adrenalectomv ~

References Suzuki et al"

,F:

Indication for Surgery (No. pts~)

size(mm,)

12 Cushing's syndrome (2), pheochromocytoma (3), aldosteronoma (51, nonfunctioning adenoma (2)

T&eda et all'

27 Cushing's syndrome (4), pheochro- Not mocytoma (11, aldosteronoma (191, nonfunctioning adenoma (3) Guazzoni et all3 20 Cushing's syndrome l3), pheochromocytoma (7).aldosteronoma (10) Brunt et all4 24 Pheochromocytoma (11). Cushing's adenoma (l),Cushing's disease (2). aldosteronoma (6). suspicion of pheochromocytoma or malignancy (2). other (2), bilat. adrenalectomy (3) Nakagawa et all5 25 Cushing's syndrome (7).aldosteronoma (8),nonfunctioning adenoma (10) Gagner" 72 Cushing's disease (6), Cushing's adenoma (7),aldosteronoma (9). pheochromocytoma (19). nonfunctional adenoma ( l l ) ,angiomyolipoma (2), macronodular hyperplasia (21, metastasis (2), Ca (2), paraneoplastic cortisolism (2), other (5), data not available ( 5 ) , bilat. adrenalectomy (7) Mean

Operative rime (mins.)

1 (ml.) 4 Loss NO. Conversion to Open Surgery (5%)

Operative Morbidity (No. pts.)

Hospital Stay (days)

23

270

370

1 (8)

available

231.8

155

1 (6)

Wound infection (l), Not available hemorrhage greater than 500 ml. l3), paralytic ileus (11,fever greater than 38C (5) Not available Not available

28

170

100

0

Wound infection (1)

3.4

27

183

104

0

Renal injury I l ) , atrial fibrillation ( 1)

3.2

25

254

Not available

0

None

41

183

Not available

2 (2.6)

Hypotensionhypertension ( 5 ) . periop. bleeding (11, subdural hematoma (1). urinary tract infection (11, hematoma (2), coloNc pseudo-obstruction (1). anemia 12)

28.8

215

182

Not available 3

3.2

TABLE4. Review o f the literature on the open posterior approach References Brunt et all4

Russel et all7 Nash et alls Proye et all9

No.

pts,

Indication for Surgery (No. pts.)

17

Cushings disease (2). Cushin$s adenoma (2). aldosteronoma (a), pheochromocytoma (l), suspicion of pheochromocytoma or malignancy (21, other (2), bilat. adrenalectomy (21 39 Cushing's disease (13), Cushing's adenoma (26), bilat. adrenalectomy (13) 40 Aldosteronoma (40) 105 Cushing's disease (191, Cushing's adenoma (18). aldosteronoma (48), virilizing tumor (2). nonfunctioning adenoma (13). metastasis (31, cyst (21, bilat. adrenalectomy (20)

Mean

I

Size (mm.) 24

Operative Time (mix.)

Blood Loss (ml.)

O/c Pleural

136

366

Not available

85

Not available

17.5

200 132

232 Not available

138

299

Less than 50 in 58 cases

retroperitoneum.Adrenalectomy is not the only indication of fetroperitoneal laparoscopy. We are now using this approach !n more and more settings, including some in which lumbar Incision was previously used, such as renal cyst excision, renal tumorectomy, simple nephrectomy, radical nephrectomy and partial nephre~tomy.~ CONCLUSIONS

Retroperitoneal laparoscopy appears to be an effective and reliable technique for adrenal surgery. It is less traumatic than open surgery and appears to be more rapid in our experience than transperitoneal laparoscopy, at the same time maintaining a low morbidity rate. These results may be explained by the lack of penetration into the abdominal cavI ~ Y avoiding , the problems and risks posed by the abdominal organs. Our study supports the use of retroperitoneal laparoscopy and contributes to its validation. At our institution retroperitoneallaparoscopy is now the standard adrenal surgery procedure for tumors less than 5 cm.

Operative Morbidity (No. pts.)

Hospital Stay (days)

17.6

Atrial fibrillation 11). blood transfusion (1)

6.2

26

None

6

None Deep venous thrombosis (3), retroperitoneal hematoma (1). duodenal ulcer hemorrhage ( 11, death from iatrogenic sepsis ( 1 )

4.4 7.6

Tears

Not available 12.4

6

REFERENCES

1. Young, H.H.: A technique for simultaneous exposure and operation of the adrenals. Surg., Gynec. & Obst., 54: 179,1936. 2. Gagner, M., Jacroix, A. and Bolte, E.: Laparoscopic adrenalectomy in Cushing's syndrome and pheochromocytoma (letter). New Engl. J. Med., 327: 1033,1992. 3. Gaur, D. D.: Laparoscopic operative retroperitoneoscopy:use of a new device. J. Urol., 148: 1137,1992. 4. Gasman, D., Saint, F., Barthelemy, Y.,Antiphon, P., Chopin, D. and Abbou, C. C.: Retroperitoneoscopy: a laparoscopic approach for adrenal and renal surgery. Urology, 47: 801,1996. 5. Gill, I. S., Grune, M. T. and Munch, L. C.: Access technique for retroperitoneoscopy.J. Urol., 156: 1120,1996. 6. Wolf, J.S., Monk, T. G., McDougall,E. M., McClennan, B. L. and Clayman, R. V.: The extraperitoneal approach and subcutaneous emphysema are associated with greater absorption of carbon dioxide during renal surgery. J. Urol., 151: - laparoscopic . 959,1995. 7. Giebler, R. M., Walz, M. K., Peitgen, K. and Scherer, R. U.: Hernodynamic changes after retroperitoneal C02 insuflation

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LAPAROSCOPIC ADRENALECTOMY

for posterior retroperitoneoscopy adrenalectomy. Anesth. Anal., 8 2 827, 1996. 8. Heintz, A., Walgenbach, S. and Junginger, T.: Results of endoscopic retroperitoneal adrenalectomy. Surg. Endosc., 1 0 633, 1996. 9. Mandressi, A., Buizza, C., Antonelli, D., Chisena, S. and Servadio, G.: Retroperitoneoscopy. Ann. Urol., 29: 91, 1995. 10. Mercan, S., Seven, R., Ozarmagan, S. and Tezlman, S.: Endoscopic retroperitoneal adrenalectomy. Surgery, 1 1 8 1071, 1995. 11. Takeda, M., Go, H., Watanabe, R., Kurumada, S., Obara, K., Takahashi, E., Komeyama, T., Imai, T. and Takahashi, K.: Retroperitoneal laparoscopic adrenalectomy for functioning adrenal tumor: comparison with conventional transperitoneal laparoscopic adrenalectomy. J. Urol., 157 19, 1997. 12. Suzuki. K., Kageyama, S., Daisuke, U., Ushiyama, T., Kawabe, K., Tajima, A. and Aso, Y.: Laparoscopic adrenalectomy: clinical experience with 12 cases. J. Urol., 150 1099, 1993. 13. Guazzoni, G., Montorsi, F., Bocciardi, A,, Da Pozzo, L., Rigatti, P., Lanzi, R. and Pontiroli, A,: Transperitoneal laparoscopic versus open adrenalectomy for benign hyperfunctioning adrenal tumors: a comparative study. J. Urol., 153 1597, 1995.

14. Brunt, L. M., Doherty, G. M., Norton, J . A., Soper, N. J., Quasebarth, M. A. and Moley, J. F.: Laparoscopic adrenalectomy compared to open adrenalectomy for benign adrenal neoplasm. J . h e r . Coll. Surg., 183. 1, 1996. 15. Nakagawa, K., Murai, M., Deguchi, N., Baba, S., Tachibana, M., Nakamura, K. and Tazaki, H.: Laparoscopic adrenalectomy: clinical results in 25 patients. J . Endourol., 9 265, 1995. 16. Gagner, M.: Laparoscopic adrenalectomy. Surg. Clin. N. h e r . , 7 6 523, 1996. 17. Russel, C. F., Hamberger, B., van Heerden, J. A., Edis, A. J. and Ilstrup, D. M.: Adrenalectomy: anterior or posterior approach? Amer. J . Surg., 144: 322, 1989. 18. Nash, P. A,, Leibovitch, I. and Donohue, J . P.: Adrenalectomy via the dorsal approach: a benchmark for laparoscopic adrenalec. tomy. J . Urol., 154: 1652, 1995. 19. Proye, C. A. G., Huart, J . Y., Cuvillier, X. D., Assez, N. M. L., Gambardella, B. and Carnaille, B. M. L.: Safety of the posterior approach in adrenal surgery: experience in 105 cases. Surgery, 114: 1127, 1993. 20. Higashihara, E., Tanaka, Y., Horie, S., Aruga, S., Nutahara, K., Minowada, S. and Aso, Y.: Laparoscopic adrenalectomy: the initial 3 cases. J. Urol., 1 4 9 973, 1993.