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The anterior approach to retroperitoneoscopic adrenalectomy in children: Technique
Journal of Pediatric Urology (2012) 8, 35e39
The anterior approach to retroperitoneoscopic adrenalectomy in children: Technique Waleed Eassa, Mohamed El-Sherbiny, Roman Jednak, John-Paul Capolicchio* Division of Urology, Montreal Children’s Hospital, McGill University Health Center, Montreal, QC, Canada Received 16 November 2010; accepted 2 December 2010 Available online 13 January 2011
KEYWORDS Adrenalectomy; Retroperitoneoscopy; Laparoscopy; Children
Abstract Purpose: Very limited literature exists on minimally invasive adrenalectomy in children. Retroperitoneoscopic adrenalectomy (RPA) has the advantage of avoiding intra-abdominal organ retraction, but concerns have been expressed regarding RPA on the right side. Herein, we describe the second reported experience with the anterior approach to RPA in children, which appears to overcome the limitations previously ascribed to right RPA. Materials and methods: Two children, aged 8 and 14-years, presented with incidental right adrenal masses. Both patients were placed in the lateral decubitus position with lumbar hyper-extension. A 5-mm, 3-port approach was used, as demonstrated in the video. Results: Pathology revealed a 7-cm ganglioneuroma and a 5-cm pheochromocytoma with intact surgical margins. Operative time with these large masses and first experience with this technique was 5 h in the first case and 3.5 h in the second. No intraoperative or postoperative complications were noted, with minimal blood loss and a hospital stay of 36 h in both cases. Conclusion: The anterior approach to RPA is feasible even in children with a smaller retroperitoneal space and a large adrenal mass. It provides excellent exposure of the adrenal gland and vein, even on the right side. ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Laparoscopic adrenalectomy is now the gold standard for removal of most benign adrenal masses in adults. The literature on laparoscopic adrenalectomy in children is
* Corresponding author. Montreal Children’s Hospital, 2300 Rue Tupper, Room C5.27, Montreal, Quebec, Canada H3H 1P3. Tel.: þ1 514 412 4316; fax: þ1 514 412 4384. E-mail address: [email protected] (J.-P. Capolicchio).
sparse, and even rarer is reports of retroperitoneoscopic approaches in children, likely due to the rarity of the disease. The retroperitoneoscopic approach to adrenalectomy provides the advantage of not having to mobilize and retract the liver or spleen. Despite this advantage, difficulty with exposure of the adrenal vessels on the right side has led to some authors recommending that a right adrenalectomy should be done via transperitoneal laparoscopy instead, both in children and adults [1e3]. Zhang et al. [4] first described the anterior approach to retroperitoneoscopic adrenalectomy (RPA) in 2007 with 800 cases in adults, providing excellent outcomes for both the
1477-5131/$36 ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2010.12.007
36
W. Eassa et al.
left and right side. Herein, we confirm the advantageous exposure provided by the technique and its applicability to children with very large adrenal masses, even on the right side. To our knowledge, this includes the largest adrenal mass yet excised via a retroperitoneal route in a child.
Materials and methods Patients The first child was an 8-year-old male who presented with an incidentally detected right adrenal mass which measured 7 5 4 cm on magnetic resonance imaging (MRI) (Fig. 1A, B, C) without signs of infiltration. Serum aldosterone was equivocally elevated with the remaining laboratory profile unremarkable. The second child was a 14-year-old male with Von Hippel Lindau syndrome who was found to be hypertensive with elevated serum catecholamines. Abdominal imaging, which had not been performed in years, demonstrated a right adrenal mass measuring 5 4 4 cm by MRI. He underwent pre-operative and intraoperative a and b blockade.
Technique: (see attached VIDEO) Supplementary video related to this article can be found at doi:10.1016/j.jpurol.2010.12.007. Patients were placed in the left lateral decubitus position with lumbar hyper-extension, and a standard 3-port
Figure 1
approach was used (Fig. 2). We used our previously reported modified access technique [5] thus placing the first port, 10 mm, at the costo-vertebral angle. A 5-mm, zerodegree telescope and 15 mm Hg insufflation pressure were used to create the retroperitoneal space under direct vision. Ancillary 5-mm ports were placed in the mid-axillary line just above the iliac crest and the third one at the anterior axillary line, on the same level as the first port. The telescope was then transferred to the mid-axillary port for control by the assistant. The first plane of dissection, anterior to the upper pole of the kidney, was bluntly created by separating the kidney and peritoneum and then continued cranially to expose the anterior surface of the adrenal (Fig. 3A). The peritoneum is pushed off the adrenal without manipulation of the adrenal gland. The second plane of dissection then involved separating the upper pole of the kidney from the inferior surface of the adrenal, again performed by caudal traction of the kidney so as not to manipulate the adrenal gland (Fig. 3B). The third plane of dissection involved medial exposure of the adrenal gland off of the peritoneum and inferior vena cava, thus exposing the adrenal vessels (Fig. 3C). The adrenal vein was clipped on the patient’s side and divided on the adrenal side with the LigaSure device (Covidien, Dublin, Ireland) (Fig. 3D). The superior and lateral attachments, which were kept throughout the procedure to suspend and retract the adrenal, were the last to be divided, hence permitting a no-touch technique. The gland was retrieved intact after placement in an entrapment sac and extension of the 10-mm port incision.
MRI (A axial, B sagittal and C coronal).
The anterior approach to retroperitoneoscopic adrenalectomy in children
Figure 2
Port sites and positioning.
Results The anterior approach to right RPA in children was completed successfully in both patients with no intraoperative or postoperative complications and no open conversion. Blood loss was negligible in both cases. We did not experience any hypertensive bouts intraoperatively. Mean operative time was 4 h (5 h in first case and 3.5 h in second, with significant involvement of fellow for training purpose in the second case). Removed specimens were grossly 7 cm and 5 cm in their maximum diameter and weighed 60 and 40 g respectively, with intact margins on pathology. The first proved to be a ganglioneuroma and the second a pheochromocytoma. Both patients were discharged home after 36 h.
Discussion Since its first description in 1992 in three cases [6], laparoscopic adrenalectomy has rapidly replaced open adrenalectomy for removal of benign lesions of the adrenal. Since that time, retroperitoneoscopic lateral [3] and posterior [7] approaches have also been described. Regardless of the approach used, the majority of the literature both on techniques and clinical outcomes is based on adult cohorts. This is not surprising, considering the relative rarity of benign adrenal disease in children, since neuroblastoma is the most common adrenal mass in children. In fact, specific to RPA in children we could only identify four cohort studies in the literature describing a total of 22 patients including 3 by lateral RPA [1,8,9] and 1 by posterior RPA [10]. Considering the few reports about children and the small cohorts usually described within those reports, we believe that our small cohort is nevertheless an important contribution since it highlights a novel approach that we enthusiastically suggest deserves more attention. In addition, since techniques described in adults are not always applicable to children, we feel it is important to emphasize when a technique has been confirmed to have equal merit in the pediatric population. The transperitoneal approach has the advantage of a wider working space and operator’s familiarity with
37
the anatomy. On the other hand, retroperitoneoscopic approaches offer direct access to the adrenal gland, thus avoiding bowel handling, and more importantly mobilization and retraction of the liver or spleen. Thus, the transperitoneal approaches usually require a 4th port for this additional retraction [11]. While some comparative studies showed no significant differences in operative time, estimated blood loss, specimen weight or complication rates between the two approaches [12], others stated the superiority of retroperitoneoscopy over laparoscopy especially if the mass is less than 5 cm [13]. When evaluating retroperitoneal approaches specifically in the pediatric population, both the lateral [8] and to a lesser extent the posterior prone [10] techniques have been described. While some have found the lateral RPA equally effective in bilateral cases [9], many have concluded that lateral RPA provides poor exposure of the vasculature on the right side, with subsequent increased risk of bleeding and open conversion [1,2]. This opinion has been voiced even in the adult literature on lateral RPA by renown experts [3] who similarly advocated a transperitoneal approach for the right side. Recently, Zhang and co-workers reported the efficacy of an innovative anterior RPA technique which they called anatomical retroperitoneoscopic adrenalectomy [4]. They achieved excellent surgical results in 800 cases with a mean operative time of 45 min (range 25e230) and mean estimated blood loss of 25 ml. Minor perioperative complications were reported only in 12 (1.5%) patients while no major ones occurred. Open conversion was decided only in 1 case (0.1%). We decided to try their approach after struggling for 2 h with poor lateral exposure of the adrenal during our first case. After switching to an anterior exposure the procedure progressed without hindrance. In essence, the anterior RPA provides a view similar to transperitoneal laparoscopy, but without the need to retract the liver. The port placement is identical to that of a lateral RPA, but the strategy of exposure is the critical difference. The benefit of this change in surgical exposure is intuitively difficult to grasp, hence our reluctance to try it in the first case, and yet dramatically apparent once attempted. Although the posterior prone RPA approach has not been reported to be less effective on the right side, it suffers from other drawbacks that make it less appealing in our mind, and likely explain its relatively lower popularity in the literature. In particular, the prone approach may be less popular because of concerns over difficult open access in the case of emergent conversion for bleeding from the great vessels. In addition, the prone position itself can be risky if any urgent anesthetic procedures are needed such as reintubation or resuscitation. Practical anesthetic procedures that are relatively straightforward or familiar in the supine patient become more complex in the prone position [14]. The insufflation pressure needed to create the retroperitoneal space is usually high; while this improves intraoperative hemostasis and allows for better visualization, the vena cava is compressed and loses its tubular appearance, its lateral edge appearing only as a longitudinal line [15]. On the other hand, this compression causes shift of venous return to the collateral smaller veins with subsequent engorgement and risk of bleeding that is not readily apparent except after reducing the pressure [14].
38
W. Eassa et al.
Figure 3 (A) Anterior surface of the upper pole of the kidney and adrenal. (B) Dissecting the plane between the inferior adrenal and the upper renal pole. (C) Medial dissection of the adrenal, exposing the inferior vena cava. (D) Control of the adrenal vein. (E) Specimen completely mobilized.
Size of the adrenal mass is predictive of the likelihood of malignancy and has been used to decide on open versus endoscopic adrenalectomy [16]. While it is technically feasible to remove large masses greater than 5 cm in size endoscopically, this cohort is associated with a higher complication rate and higher rate of open conversion [17]. This is even more challenging in children due to their smaller body size and hence the smaller working space. In addition, malignancy is thought to be more common in children since neuroblastic tumors are the most common [11]. Laparoscopic removal of a large adrenal mass in a child is a reportable event and usually approached via a transperitoneal approach [18]. In the limited number of children operated on by RPA, all masses were limited to
a size of less than 5e6 cm [1,8e10], which would make our first case the largest adrenal mass excised via a retroperitoneal route in a child. The longer operative time in this case is testament to the cautious and meticulous technique. On the other hand, many others feel that large size is only a relative contra-indication, to be tempered by surgeon experience on an individual case basis with the knowledge on the part of the family and the surgeon that early open conversion is more likely [11,17,19]. Certainly, signs of invasion on imaging such as adenopathy, vascular infiltration and irregular mass are very concerning. Nevertheless, as experience with endoscopic adrenalectomy in children progresses, we are beginning to see descriptions in known neuroblastoma, even after chemotherapy [20e22].
The anterior approach to retroperitoneoscopic adrenalectomy in children
Conclusion Our experience provides the first corroboration of the feasibility of the anatomical retroperitoneoscopic adrenalectomy technique as advocated in adults by Zhang et al. [4]. We confirm the advantageous exposure provided by the technique and its applicability to children with very large adrenal masses and even on the right side.
Conflict of interest/funding None.
References [1] Shanberg AM, Sanderson K, Rajpoot D, Duel B. Laparoscopic retroperitoneal renal and adrenal surgery in children. BJU Int 2001;87:521e4. [2] Mirallie E, Leclair MD, de Lagausie P, Weil D, Plattner V, Duverne C, et al. Laparoscopic adrenalectomy in children. Surg Endosc 2001;15:156e60. [3] Sung GT, Hsu TH, Gill IS. Retroperitoneoscopic adrenalectomy: lateral approach. J Endourol 2001;15:505e11. discussion 11e2. [4] Zhang X, Fu B, Lang B, Zhang J, Xu K, Li HZ, et al. Technique of anatomical retroperitoneoscopic adrenalectomy with report of 800 cases. J Urol 2007;177:1254e7. [5] Capolicchio JP, Jednak R, Anidjar M, Pippi-Salle JL. A modified access technique for retroperitoneoscopic renal surgery in children. J Urol 2003;170:204e6. [6] Gagner MLA, Bolte E. Laparoscopic adrenalectomy in cushing’s syndrome and pheochromocytoma. N Eng J Med 1992:1033. [7] Walz MK, Peitgen K, Hoermann R, Giebler RM, Mann K, Eigler FW. Posterior retroperitoneoscopy as a new minimally invasive approach for adrenalectomy: results of 30 adrenalectomies in 27 patients. World J Surg 1996;20:769e74. [8] Steyaert H, Juricic M, Hendrice C, Lembo MA, Al Mohaidly M, Guitard J, et al. Retroperitoneoscopic approach to the adrenal glands and retroperitoneal tumours in children: where do we stand? Eur J Pediatr Surg 2003;13:112e5.
39
[9] Romano P, Avolio L, Martucciello G, Steyaert H, Valla JS. Adrenal masses in children: the role of minimally invasive surgery. Surg Laparosc Endosc Percutan Tech 2007;17:504e7. [10] Lopez PJ, Pierro A, Curry JI, Mushtaq I. Retroperitoneoscopic adrenalectomy: an early institutional experience. J Pediatr Urol 2007;3:96e9. [11] Skarsgard ED, Albanese CT. The safety and efficacy of laparoscopic adrenalectomy in children. Arch Surg 2005;140: 905e8. discussion 9. [12] Rubinstein M, Gill IS, Aron M, Kilciler M, Meraney AM, Finelli A, et al. Prospective, randomized comparison of transperitoneal versus retroperitoneal laparoscopic adrenalectomy. J Urol 2005;174:442e5. discussion 5. [13] Suzuki K, Kageyama S, Hirano Y, Ushiyama T, Rajamahanty S, Fujita K. Comparison of 3 surgical approaches to laparoscopic adrenalectomy: a nonrandomized, background matched analysis. J Urol 2001;166:437e43. [14] Edgcombe H, Carter K, Yarrow S. Anaesthesia in the prone position. Br J Anaesth 2008;100:165e83. [15] Callender GG, Kennamer DL, Grubbs EG, Lee JE, Evans DB, Perrier ND. Posterior retroperitoneoscopic adrenalectomy. Adv Surg 2009;43:147e57. [16] Cagle PT, Hough AJ, Pysher TJ, Page DL, Johnson EH, Kirkland RT, et al. Comparison of adrenal cortical tumors in children and adults. Cancer 1986;57:2235e7. [17] Hobart MG, Gill IS, Schweizer D, Sung GT, Bravo EL. Laparoscopic adrenalectomy for large-volume (> or Z 5 cm) adrenal masses. J Endourol 2000;14:149e54. [18] Shah SR, Purcell GP, Malek MM, Kane TD. Laparoscopic right adrenalectomy for a large ganglioneuroma in a 12-year-old. J Laparoendosc Adv Surg Tech A 2009. [19] Zhang X, Lang B, Ouyang JZ, Fu B, Zhang J, Xu K, et al. Retroperitoneoscopic adrenalectomy without previous control of adrenal vein is feasible and safe for pheochromocytoma. Urology 2007;69:849e53. [20] de Lagausie P, Berrebi D, Michon J, Philippe-Chomette P, El Ghoneimi A, Garel C, et al. Laparoscopic adrenal surgery for neuroblastomas in children. J Urol 2003;170:932e5. [21] Leclair MD, de Lagausie P, Becmeur F, Varlet F, Thomas C, Valla JS, et al. Laparoscopic resection of abdominal neuroblastoma. Ann Surg Oncol 2008;15:117e24. [22] Iwanaka T, Kawashima H, Uchida H. The laparoscopic approach of neuroblastoma. Semin Pediatr Surg 2007;16:259e65.
The anterior approach to retroperitoneoscopic adrenalectomy in children: Technique Waleed Eassa, Mohamed El-Sherbiny, Roman Jednak, John-Paul Capolicchio* Division of Urology, Montreal Children’s Hospital, McGill University Health Center, Montreal, QC, Canada Received 16 November 2010; accepted 2 December 2010 Available online 13 January 2011
KEYWORDS Adrenalectomy; Retroperitoneoscopy; Laparoscopy; Children
Abstract Purpose: Very limited literature exists on minimally invasive adrenalectomy in children. Retroperitoneoscopic adrenalectomy (RPA) has the advantage of avoiding intra-abdominal organ retraction, but concerns have been expressed regarding RPA on the right side. Herein, we describe the second reported experience with the anterior approach to RPA in children, which appears to overcome the limitations previously ascribed to right RPA. Materials and methods: Two children, aged 8 and 14-years, presented with incidental right adrenal masses. Both patients were placed in the lateral decubitus position with lumbar hyper-extension. A 5-mm, 3-port approach was used, as demonstrated in the video. Results: Pathology revealed a 7-cm ganglioneuroma and a 5-cm pheochromocytoma with intact surgical margins. Operative time with these large masses and first experience with this technique was 5 h in the first case and 3.5 h in the second. No intraoperative or postoperative complications were noted, with minimal blood loss and a hospital stay of 36 h in both cases. Conclusion: The anterior approach to RPA is feasible even in children with a smaller retroperitoneal space and a large adrenal mass. It provides excellent exposure of the adrenal gland and vein, even on the right side. ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction Laparoscopic adrenalectomy is now the gold standard for removal of most benign adrenal masses in adults. The literature on laparoscopic adrenalectomy in children is
* Corresponding author. Montreal Children’s Hospital, 2300 Rue Tupper, Room C5.27, Montreal, Quebec, Canada H3H 1P3. Tel.: þ1 514 412 4316; fax: þ1 514 412 4384. E-mail address: [email protected] (J.-P. Capolicchio).
sparse, and even rarer is reports of retroperitoneoscopic approaches in children, likely due to the rarity of the disease. The retroperitoneoscopic approach to adrenalectomy provides the advantage of not having to mobilize and retract the liver or spleen. Despite this advantage, difficulty with exposure of the adrenal vessels on the right side has led to some authors recommending that a right adrenalectomy should be done via transperitoneal laparoscopy instead, both in children and adults [1e3]. Zhang et al. [4] first described the anterior approach to retroperitoneoscopic adrenalectomy (RPA) in 2007 with 800 cases in adults, providing excellent outcomes for both the
1477-5131/$36 ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2010.12.007
36
W. Eassa et al.
left and right side. Herein, we confirm the advantageous exposure provided by the technique and its applicability to children with very large adrenal masses, even on the right side. To our knowledge, this includes the largest adrenal mass yet excised via a retroperitoneal route in a child.
Materials and methods Patients The first child was an 8-year-old male who presented with an incidentally detected right adrenal mass which measured 7 5 4 cm on magnetic resonance imaging (MRI) (Fig. 1A, B, C) without signs of infiltration. Serum aldosterone was equivocally elevated with the remaining laboratory profile unremarkable. The second child was a 14-year-old male with Von Hippel Lindau syndrome who was found to be hypertensive with elevated serum catecholamines. Abdominal imaging, which had not been performed in years, demonstrated a right adrenal mass measuring 5 4 4 cm by MRI. He underwent pre-operative and intraoperative a and b blockade.
Technique: (see attached VIDEO) Supplementary video related to this article can be found at doi:10.1016/j.jpurol.2010.12.007. Patients were placed in the left lateral decubitus position with lumbar hyper-extension, and a standard 3-port
Figure 1
approach was used (Fig. 2). We used our previously reported modified access technique [5] thus placing the first port, 10 mm, at the costo-vertebral angle. A 5-mm, zerodegree telescope and 15 mm Hg insufflation pressure were used to create the retroperitoneal space under direct vision. Ancillary 5-mm ports were placed in the mid-axillary line just above the iliac crest and the third one at the anterior axillary line, on the same level as the first port. The telescope was then transferred to the mid-axillary port for control by the assistant. The first plane of dissection, anterior to the upper pole of the kidney, was bluntly created by separating the kidney and peritoneum and then continued cranially to expose the anterior surface of the adrenal (Fig. 3A). The peritoneum is pushed off the adrenal without manipulation of the adrenal gland. The second plane of dissection then involved separating the upper pole of the kidney from the inferior surface of the adrenal, again performed by caudal traction of the kidney so as not to manipulate the adrenal gland (Fig. 3B). The third plane of dissection involved medial exposure of the adrenal gland off of the peritoneum and inferior vena cava, thus exposing the adrenal vessels (Fig. 3C). The adrenal vein was clipped on the patient’s side and divided on the adrenal side with the LigaSure device (Covidien, Dublin, Ireland) (Fig. 3D). The superior and lateral attachments, which were kept throughout the procedure to suspend and retract the adrenal, were the last to be divided, hence permitting a no-touch technique. The gland was retrieved intact after placement in an entrapment sac and extension of the 10-mm port incision.
MRI (A axial, B sagittal and C coronal).
The anterior approach to retroperitoneoscopic adrenalectomy in children
Figure 2
Port sites and positioning.
Results The anterior approach to right RPA in children was completed successfully in both patients with no intraoperative or postoperative complications and no open conversion. Blood loss was negligible in both cases. We did not experience any hypertensive bouts intraoperatively. Mean operative time was 4 h (5 h in first case and 3.5 h in second, with significant involvement of fellow for training purpose in the second case). Removed specimens were grossly 7 cm and 5 cm in their maximum diameter and weighed 60 and 40 g respectively, with intact margins on pathology. The first proved to be a ganglioneuroma and the second a pheochromocytoma. Both patients were discharged home after 36 h.
Discussion Since its first description in 1992 in three cases [6], laparoscopic adrenalectomy has rapidly replaced open adrenalectomy for removal of benign lesions of the adrenal. Since that time, retroperitoneoscopic lateral [3] and posterior [7] approaches have also been described. Regardless of the approach used, the majority of the literature both on techniques and clinical outcomes is based on adult cohorts. This is not surprising, considering the relative rarity of benign adrenal disease in children, since neuroblastoma is the most common adrenal mass in children. In fact, specific to RPA in children we could only identify four cohort studies in the literature describing a total of 22 patients including 3 by lateral RPA [1,8,9] and 1 by posterior RPA [10]. Considering the few reports about children and the small cohorts usually described within those reports, we believe that our small cohort is nevertheless an important contribution since it highlights a novel approach that we enthusiastically suggest deserves more attention. In addition, since techniques described in adults are not always applicable to children, we feel it is important to emphasize when a technique has been confirmed to have equal merit in the pediatric population. The transperitoneal approach has the advantage of a wider working space and operator’s familiarity with
37
the anatomy. On the other hand, retroperitoneoscopic approaches offer direct access to the adrenal gland, thus avoiding bowel handling, and more importantly mobilization and retraction of the liver or spleen. Thus, the transperitoneal approaches usually require a 4th port for this additional retraction [11]. While some comparative studies showed no significant differences in operative time, estimated blood loss, specimen weight or complication rates between the two approaches [12], others stated the superiority of retroperitoneoscopy over laparoscopy especially if the mass is less than 5 cm [13]. When evaluating retroperitoneal approaches specifically in the pediatric population, both the lateral [8] and to a lesser extent the posterior prone [10] techniques have been described. While some have found the lateral RPA equally effective in bilateral cases [9], many have concluded that lateral RPA provides poor exposure of the vasculature on the right side, with subsequent increased risk of bleeding and open conversion [1,2]. This opinion has been voiced even in the adult literature on lateral RPA by renown experts [3] who similarly advocated a transperitoneal approach for the right side. Recently, Zhang and co-workers reported the efficacy of an innovative anterior RPA technique which they called anatomical retroperitoneoscopic adrenalectomy [4]. They achieved excellent surgical results in 800 cases with a mean operative time of 45 min (range 25e230) and mean estimated blood loss of 25 ml. Minor perioperative complications were reported only in 12 (1.5%) patients while no major ones occurred. Open conversion was decided only in 1 case (0.1%). We decided to try their approach after struggling for 2 h with poor lateral exposure of the adrenal during our first case. After switching to an anterior exposure the procedure progressed without hindrance. In essence, the anterior RPA provides a view similar to transperitoneal laparoscopy, but without the need to retract the liver. The port placement is identical to that of a lateral RPA, but the strategy of exposure is the critical difference. The benefit of this change in surgical exposure is intuitively difficult to grasp, hence our reluctance to try it in the first case, and yet dramatically apparent once attempted. Although the posterior prone RPA approach has not been reported to be less effective on the right side, it suffers from other drawbacks that make it less appealing in our mind, and likely explain its relatively lower popularity in the literature. In particular, the prone approach may be less popular because of concerns over difficult open access in the case of emergent conversion for bleeding from the great vessels. In addition, the prone position itself can be risky if any urgent anesthetic procedures are needed such as reintubation or resuscitation. Practical anesthetic procedures that are relatively straightforward or familiar in the supine patient become more complex in the prone position [14]. The insufflation pressure needed to create the retroperitoneal space is usually high; while this improves intraoperative hemostasis and allows for better visualization, the vena cava is compressed and loses its tubular appearance, its lateral edge appearing only as a longitudinal line [15]. On the other hand, this compression causes shift of venous return to the collateral smaller veins with subsequent engorgement and risk of bleeding that is not readily apparent except after reducing the pressure [14].
38
W. Eassa et al.
Figure 3 (A) Anterior surface of the upper pole of the kidney and adrenal. (B) Dissecting the plane between the inferior adrenal and the upper renal pole. (C) Medial dissection of the adrenal, exposing the inferior vena cava. (D) Control of the adrenal vein. (E) Specimen completely mobilized.
Size of the adrenal mass is predictive of the likelihood of malignancy and has been used to decide on open versus endoscopic adrenalectomy [16]. While it is technically feasible to remove large masses greater than 5 cm in size endoscopically, this cohort is associated with a higher complication rate and higher rate of open conversion [17]. This is even more challenging in children due to their smaller body size and hence the smaller working space. In addition, malignancy is thought to be more common in children since neuroblastic tumors are the most common [11]. Laparoscopic removal of a large adrenal mass in a child is a reportable event and usually approached via a transperitoneal approach [18]. In the limited number of children operated on by RPA, all masses were limited to
a size of less than 5e6 cm [1,8e10], which would make our first case the largest adrenal mass excised via a retroperitoneal route in a child. The longer operative time in this case is testament to the cautious and meticulous technique. On the other hand, many others feel that large size is only a relative contra-indication, to be tempered by surgeon experience on an individual case basis with the knowledge on the part of the family and the surgeon that early open conversion is more likely [11,17,19]. Certainly, signs of invasion on imaging such as adenopathy, vascular infiltration and irregular mass are very concerning. Nevertheless, as experience with endoscopic adrenalectomy in children progresses, we are beginning to see descriptions in known neuroblastoma, even after chemotherapy [20e22].
The anterior approach to retroperitoneoscopic adrenalectomy in children
Conclusion Our experience provides the first corroboration of the feasibility of the anatomical retroperitoneoscopic adrenalectomy technique as advocated in adults by Zhang et al. [4]. We confirm the advantageous exposure provided by the technique and its applicability to children with very large adrenal masses and even on the right side.
Conflict of interest/funding None.
References [1] Shanberg AM, Sanderson K, Rajpoot D, Duel B. Laparoscopic retroperitoneal renal and adrenal surgery in children. BJU Int 2001;87:521e4. [2] Mirallie E, Leclair MD, de Lagausie P, Weil D, Plattner V, Duverne C, et al. Laparoscopic adrenalectomy in children. Surg Endosc 2001;15:156e60. [3] Sung GT, Hsu TH, Gill IS. Retroperitoneoscopic adrenalectomy: lateral approach. J Endourol 2001;15:505e11. discussion 11e2. [4] Zhang X, Fu B, Lang B, Zhang J, Xu K, Li HZ, et al. Technique of anatomical retroperitoneoscopic adrenalectomy with report of 800 cases. J Urol 2007;177:1254e7. [5] Capolicchio JP, Jednak R, Anidjar M, Pippi-Salle JL. A modified access technique for retroperitoneoscopic renal surgery in children. J Urol 2003;170:204e6. [6] Gagner MLA, Bolte E. Laparoscopic adrenalectomy in cushing’s syndrome and pheochromocytoma. N Eng J Med 1992:1033. [7] Walz MK, Peitgen K, Hoermann R, Giebler RM, Mann K, Eigler FW. Posterior retroperitoneoscopy as a new minimally invasive approach for adrenalectomy: results of 30 adrenalectomies in 27 patients. World J Surg 1996;20:769e74. [8] Steyaert H, Juricic M, Hendrice C, Lembo MA, Al Mohaidly M, Guitard J, et al. Retroperitoneoscopic approach to the adrenal glands and retroperitoneal tumours in children: where do we stand? Eur J Pediatr Surg 2003;13:112e5.
39
[9] Romano P, Avolio L, Martucciello G, Steyaert H, Valla JS. Adrenal masses in children: the role of minimally invasive surgery. Surg Laparosc Endosc Percutan Tech 2007;17:504e7. [10] Lopez PJ, Pierro A, Curry JI, Mushtaq I. Retroperitoneoscopic adrenalectomy: an early institutional experience. J Pediatr Urol 2007;3:96e9. [11] Skarsgard ED, Albanese CT. The safety and efficacy of laparoscopic adrenalectomy in children. Arch Surg 2005;140: 905e8. discussion 9. [12] Rubinstein M, Gill IS, Aron M, Kilciler M, Meraney AM, Finelli A, et al. Prospective, randomized comparison of transperitoneal versus retroperitoneal laparoscopic adrenalectomy. J Urol 2005;174:442e5. discussion 5. [13] Suzuki K, Kageyama S, Hirano Y, Ushiyama T, Rajamahanty S, Fujita K. Comparison of 3 surgical approaches to laparoscopic adrenalectomy: a nonrandomized, background matched analysis. J Urol 2001;166:437e43. [14] Edgcombe H, Carter K, Yarrow S. Anaesthesia in the prone position. Br J Anaesth 2008;100:165e83. [15] Callender GG, Kennamer DL, Grubbs EG, Lee JE, Evans DB, Perrier ND. Posterior retroperitoneoscopic adrenalectomy. Adv Surg 2009;43:147e57. [16] Cagle PT, Hough AJ, Pysher TJ, Page DL, Johnson EH, Kirkland RT, et al. Comparison of adrenal cortical tumors in children and adults. Cancer 1986;57:2235e7. [17] Hobart MG, Gill IS, Schweizer D, Sung GT, Bravo EL. Laparoscopic adrenalectomy for large-volume (> or Z 5 cm) adrenal masses. J Endourol 2000;14:149e54. [18] Shah SR, Purcell GP, Malek MM, Kane TD. Laparoscopic right adrenalectomy for a large ganglioneuroma in a 12-year-old. J Laparoendosc Adv Surg Tech A 2009. [19] Zhang X, Lang B, Ouyang JZ, Fu B, Zhang J, Xu K, et al. Retroperitoneoscopic adrenalectomy without previous control of adrenal vein is feasible and safe for pheochromocytoma. Urology 2007;69:849e53. [20] de Lagausie P, Berrebi D, Michon J, Philippe-Chomette P, El Ghoneimi A, Garel C, et al. Laparoscopic adrenal surgery for neuroblastomas in children. J Urol 2003;170:932e5. [21] Leclair MD, de Lagausie P, Becmeur F, Varlet F, Thomas C, Valla JS, et al. Laparoscopic resection of abdominal neuroblastoma. Ann Surg Oncol 2008;15:117e24. [22] Iwanaka T, Kawashima H, Uchida H. The laparoscopic approach of neuroblastoma. Semin Pediatr Surg 2007;16:259e65.