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Use of laparoscopic techniques improves outcome from adrenalectomy
Use of Laparoscopic Techniques Improves Outcome from Adrenalectomy Santiago
Horgan MD, Mika Sinanan, MD, PhD, W. Scott Helton, MD, Carlos A. Pellegrini, MD, Seattle, Washington
BACKGROUND: Laparoscopic adrenalectomy is a promising alternative to open approaches but safety and efficacy remain unproven. METHODS: A recent experience with laparoscopic adrenalectomy at the University of Washington was analyzed for efficacy, complications, evolution of technical steps, and clinical outcome. RESULTS: Ninteen adrenalectomies were performed in 16 patients with a mean age of 52 years. Indications included pheochromocytoma (4), functional adenoma (12), and uncontrolled Cushing’s disease (3). All patients had computed tomography scans. Meta-iodo-benzyl-guanidine (MIBG) or iodocholesterol scans were done in selected patients. Three patients had bilateral procedures, 7 were on the left and 6 on the right, all via a transperitoneal flank approach. There were no conversions and all procedures were successful. Complications included subcapsular liver hematomas (2), one transfusion, and a bleeding port site requiring repeat laparoscopy. Except for 1 patient with COPD, the mean length of stay was 2.9 days. CONCLUSIONS: Laparoscopic adrenalectomy in appropriate patients is safe and effective. For endocrine surgeons with advanced laparostopic skills, it should be considered a new standard therapy for benign adrenal tumors. Am J Sot-g. 1997;173:371-374. 0 1997 by Excerpta Medica, Inc.
laparoscopic skills are important to success with the procedure. This article presents our initial experience at the University of Washington with the transperitoneal, flank approach of Gagner et al.’
PATIENTS
M
inimally invasive surgical techniques have improved since laparoscopic cholecystectomy was first introduced in the late 1980s. Better instrumentation and an expanded array of endoscopic surgical skills now permit laparoscopic treatment for a wide range of abdominal and retroperitoneal surgical diseases. Laparoscopic adrenalectomy was first described by Gagner et al’ in 1993 and since then, several alternative approaches to the gland have been described and a growing experience in this area achieved.? This early experience suggests that familiarity with the vascular relationships and anatomic variations for both right and left glands as well as advanced From the Department of Surgery, University of Washington, Seattle, Washington. Requests for reprints should be addressed to Mika N. Sinanan, MD, PhD, HSB BB-430, 1959 N.E. Pacific St., Box 356410, Seattle, Washington 981956410. Presented at the 83rd Annual Meeting of the North Pacific Surgical Association, Seattle, Washington, November 8-9, 1996. I
0 1997 by Excerpta All rights reserved.
Medica,
Inc.
AND
METHODS
From January 1994 to October 1996, 16 patients underwent laparoscopic adrenalectomy at the University of Washington. Indications for surgery were adrenal cortical adenoma (functional and nonfunctional), benign pheochromocytoma, and recurrent or untreatable Cushing’s disease. Contraindications were adrenal carcinoma and malignant pheochromocytoma. Malignant lesions were excluded from consideration because of the limited margins of resection and the potential difficulty with resection of these often vascular lesions. Localization of disease was carried out with a combination of radiographic and nuclear medicine studies, essential because of the narrow exploratory field available with the laparoscopic flank approach. Iodocholesterol scans4 helped confirm activity in 5 patients with small cortical adenomas poorly visualized by computed tomography (CT) while meta-iodo-benzyl-guanidine (MIBG) scans localized the increased catecholamine activity in all patients with pheochromocytoma. The CT scans were carried out in all patients to establish the anatomic relations of the involved gland, particularly useful in finding and isolating the adrenal on the left side. All pheochromocytoma patients received phenoxybenzamine starting at 10 mg per day and increasing to 20 to 30 mg per day until patients achieved a normal blood pressure. This treatment was carried out for a minimum of 10 days to allow the patient to equilibrate intravascular volume, minimizing the risk of acute hypertension or hypotension during anesthesia and manipulation of the adrenal gland. Tachycardia (pulse >lOO beats per minute from the beta agonist effects of circulating catecholamines) was treated with beta blockade as necessary, but for most patients this was not required. All patients received a mild cathartic as outpatients to avoid the presence of a full colon (hepatic or splenic flexure) in the surgical field. Surgical Technique All patients received arterial lines for monitoring of blood pressure. Intravenous alpha and beta agonist and antagonist drugs were immediately available for management of blood pressure swings in all patients with pheochromocytoma. Access to the retroperitoneum was made via the transperitoneal flank approach as described by Gagner et al.’ Patients were positioned on a bean bag with an axillary pad and the 0002-9610/97/$17.00 PII SOOO2-9610(96)00069-X
371
( LAPAROSCOPIC
ADRENALECTOMYlHORGAN
ET AL 1
operating room table extended at the waist to open the patient’s costopelvic space (Figure 1). The patient’s upper arm was suspended overhead with an airplane splint and both arm and hip were secured with wide tape or a belt. Rotating the patient into operative position before skin preparation and draping was important to assure proper adjustment of the arm and body position. The surgeon’s operative ports were placed on the costal margin in the mid clavicular (left hand) and mid axillary line (right hand) with the camera port between them and displaced back one hand’s breadth off the costal margin in the anterior axillary line (Figure 1, “x” skin marks). The righthand port was 12 mm in size for the possible use of a linear stapler, while the other two ports were 10 to 11 mm disposable ports. In most patients, an additional 5-mm port was placed later in the posterior axillary line off the costal margin for placement of an EndoKitner (U.S. Surgical Inc., Norwalk, CT) or other i-mm instruments to assist with retraction. For both right and left sides, the initial port placed was the camera port using an open technique to avoid injury to the liver on the right or a semiopen technique (elevation of the fascia for Verress needle placement) on the left, to minimize the risk of injury to the splenic flexure of the colon. Left Side On the left side, the adrenal gland is found off the medial, superior pole of the left kidney behind the splenlienal ligaments. Thus, the first step in the procedure is division of the lienorenal attachments, exposing Gerota’s fascia. The left adrenal gland is then found by opening Gerota’s fascia onto the superior pole of the kidney and dissecting medially and parallel to the ventromedial surface of the kidney. This maneuver is an important step since it orients the dissection away from the other glandular structure that might extend into the same area, namely, the tail of the pancreas. The adrenal gland is usually bright yellow and has a solid, platelike movement when pressed that distinguishes it from the surrounding fat that often obscures the margins of the gland. Once localized, arterial branches to the adrenal are divided superiorly (phrenic origin), medially (aortic origin), then inferiorly (renal artery origin) between clips or with cautery. Leaving areolar tissue attached to the adrenal facilitates manipulation of the gland as does use of an pretied loop (Fig-
Figure 1. Lateral decubitus for access to the left adrenal 372
THE
AMERICAN
position gland.
JOURNAL
and planned
OF SURGERY”
port
positions
VOLUME
173
Figure 2. Placement of a EndoLoop (Ethicon, Cincinnati, ventrolateral retraction of the right adrenal gland.
OH) for
ure 2), secured about the partially mobilized gland for subsequent posterior dissection. The left adrenal vein is usually posteriorly directed off the inferior pole of the gland, extending down to the left renal vein. Multiple vein branches are often present. Early division of the vein is often impossible, emphasizing the necessity for adequate preoperative pharmacological control in patients with a left-sided pheochromocytoma. Division of these vessels is often facilitated by use of the linear cutting device, or a right-angled multime stapler (Origin, Menlo Park, CA). The final dissection may require close cooperation between the anesthesiologist and surgeon since it is during this phase that most manipulation of the gland occurs. Right Side On the right, the liver must be mobilized laterally to include much of the bare area-attachment to the diaphragm. If the liver does not fall forward adequately to expose the medial aspect of the kidney and lateral aspect of the cava, an additional port and liver retractor may be necessary. This is usually placed between the scope and the surgeon’s righthand port. Following lateral mobilization of the liver, the adrenal is localized in Gerota’s fascia by opening the fascia and palpating for the platelike form of the gland off the medial superior aspect of the kidney. Next, the vena cava is exposed from just below the inferior liver margin superiorly and laterally, eventually demonstrating the inferior border of the right adrenal vein. Care must be taken to distinguish this from the renal vein or superior pole accessory renal veins, which may enter in close proximity. Following mobilization of the vein, it can be divided between multiple clips or with the linear cutter. Achieving adequate length to the vein is rarely a problem. Further dissection of the gland superiorly, behind the vein, and inferiorly exposes all arterial branches and eventually permits full mobilization of the gland. As with resection of the left gland, care to avoid tearing of the gland is critical since this can lead to unacceptable bleeding. Use of the pretied loop retractor is helpful in this regard. After full mobilization of the gland, placement of fascial closure sutures, and optionally a drain into the adrenal bed through the 5.mm port site, is followed by retrieval of the gland in an endoscopic bag, brought out through the 12mm port site to keep the gland intact. aAY
1997
RESULTS From January 1994 to October 1996, 16 patients underwent a laparoscopic adrenalectomy at the University of Washington Medical Center. These represent a consecutive series of referred patients. Contraindications to laparoscopic adrenalectomy include malignancy (absolute) or prior upper abdominal surgery on the involved side (relative) but, in practice, no patient referred for the procedure had a malignancy and no patient was denied laparoscopic treatment. Nine of these 16 patients were women and 7 were men. The mean age was 52 years (range 29 to 71). Of the 16 patients presented in this report, 3 underwent a bilateral adrenalectomy for otherwise uncontrollable Cushing’s disease and the rest had a unilateral benign pheochromocytoma (4 patients) or functional (cortisol or aldosterone secreting) adenoma ( 12 patients). Workup to localize the site of the disease included MIBG scans (3 studies), iodocholesterol scan (5 studies), and CT in all patients. Of the patients having unilateral procedures, 7 were on the left side and 6 on the right. In 3 patients undergoing right adrenalectomy, an extra port was necessary for liver retraction. The adrenal vein was controlled with clips alone in a majority of cases (16 patients) while a vascular 2.5-mm linear cutting instrument was used for the remaining 3 glands. Blood loss was minimal (
COMMENTS Since 1994, 19 adrenal glands have been removed using a laparoscopic flank approach. This represents an early experience, but for the most part, complications have been THE
AMERICAN
minor and manageable. All glands approached laparoscopically have been successfully resected without conversion to an open procedure. Based on this experience, we have derived several critical insights to successful completion of the procedure that deserve emphasis. First, proper placement of the port sites at the costal margin, appropriately oriented to liver or spleen and the adrenal gland, is essential to gaining safe access to the operative field. Second, the liver on the right and spleen on the left must be fully mobilized and allowed to fall under the influence of gravity, or retracted to the midline to fully expose the adrenal gland. Inadequate mobilization risks injury to those solid organs and compounds the difficulty of vascular control for both right and left glands. Third, the gland must be positively identified before extensive dissection or vascular structure ligation is carried out, a concept that is particularly critical on the left where the tail of the pancreas may be mistaken for the adrenal because of its proximity, glandular appearance, and consistency. Fourth, dissection of the gland surface, retaining areolar attachments for manipulation and retraction of the gland, is critical to avoid fracture, excessive bleeding, and potential tumor disruption. Fifth and last, closure of all lo-mm or greater port sites minimizes the risk of intercostal vessel bleeding as well as hernia formation. In general, localization and dissection of the right adrenal is more straightforward than the approach to the left gland but employment of these principles should increase the liklihood of success for the surgeon initiating practice with these techniques. Although this observational study suggests a favorable outcome with reduced length of stay and shorter recovery, it does not permit a direct comparison with patients treated by other methods, particularly the posterior, 12th-rib approach. However, other authors have performed this comparison and patient outcomes in our study compare favorably with their laparoscopic study groups. Duh et al” showed that patients undergoing laparoscopic flank and posterior approaches have a similar utilization of inpatient resources so the net benefit of the laparoscopic procedure was smaller incisions and avoidance of a rib resection. Proye et a1,7 in an experience with the open posterior approach, found a significantly longer mean hospital stay of 7.6 days. Prinz’ in 1995 analyzed his own patients and summarized the published data on open posterior and laparoscopic adrenalectomy, demonstrating less pain and an apparently reduced hospital stay with the laparoscopic approach. In aggregate, these published studies’,@ and our cohort included 74 patients treated via laparoscopic techniques. Although laparoscopic adrenalectomy is a technique that likely still warrants refinements in instrumentation and technical performance, this collective early experience, the obvious rapid recovery of our patients, and the enthusiasm of referring endocrinologists illustrates that it is a promising procedure that may well represent the next standard for management of nonmalignant adrenal tumors.
REFERENCES 1. Gagner M, Lacroix A, Prim R, et al. Early experience with laparoscopic approach for adrenalectomy. Surgery. 1993;114:11201125. 2. Mercan S, Seven toned adrenalectomy. JOURNAL
R, Ozarmagan S, et al. Endoscopic Surgery. 1995;118:1071-1076.
OF SURGERY@
VOLUME
173
MAY
retroperi-
1997
373
3. Gagner M, Lecroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s and pheuchromocytoma. NEJM. 1992;327:1033. 4. Yu KC, Alexander HR, Ziessman HA, et al. Role of preoperative iodocholesterol scintiscanning in patients undergoing adrenalectomy for Gushing’s syndrome. Surgery. 1995;118:981-987. 5. Gagner M, Lacroix A, Bolte E, et al. Laparoscopic adrenalectomy. The importance of a flank approach in the lateral decubitus position. Surg Endosc. 1994;8:135-138.
374
THE AMERICAN
JOURNAL
OF
SURGERY@
VOLUME
173
6. Duh Q, Siperstein A, Clark 0, et al. Laparoscopic adrenalectomy. Comparison of the lateral and posterior approaches. Arch Surg. 1996;131:870-875. 7. Proye C, Huart J, Cuvillier D, et al. Safety of the posterior approach in adrenal surgery: expertence in 105 cases. Surgq. 1993;114:1126-1131. 8. Prinz R. A comparison of laparoacopic and open adrenalectomies. Arch Surg. 1995;130:4899494.
MAY
1997
Horgan MD, Mika Sinanan, MD, PhD, W. Scott Helton, MD, Carlos A. Pellegrini, MD, Seattle, Washington
BACKGROUND: Laparoscopic adrenalectomy is a promising alternative to open approaches but safety and efficacy remain unproven. METHODS: A recent experience with laparoscopic adrenalectomy at the University of Washington was analyzed for efficacy, complications, evolution of technical steps, and clinical outcome. RESULTS: Ninteen adrenalectomies were performed in 16 patients with a mean age of 52 years. Indications included pheochromocytoma (4), functional adenoma (12), and uncontrolled Cushing’s disease (3). All patients had computed tomography scans. Meta-iodo-benzyl-guanidine (MIBG) or iodocholesterol scans were done in selected patients. Three patients had bilateral procedures, 7 were on the left and 6 on the right, all via a transperitoneal flank approach. There were no conversions and all procedures were successful. Complications included subcapsular liver hematomas (2), one transfusion, and a bleeding port site requiring repeat laparoscopy. Except for 1 patient with COPD, the mean length of stay was 2.9 days. CONCLUSIONS: Laparoscopic adrenalectomy in appropriate patients is safe and effective. For endocrine surgeons with advanced laparostopic skills, it should be considered a new standard therapy for benign adrenal tumors. Am J Sot-g. 1997;173:371-374. 0 1997 by Excerpta Medica, Inc.
laparoscopic skills are important to success with the procedure. This article presents our initial experience at the University of Washington with the transperitoneal, flank approach of Gagner et al.’
PATIENTS
M
inimally invasive surgical techniques have improved since laparoscopic cholecystectomy was first introduced in the late 1980s. Better instrumentation and an expanded array of endoscopic surgical skills now permit laparoscopic treatment for a wide range of abdominal and retroperitoneal surgical diseases. Laparoscopic adrenalectomy was first described by Gagner et al’ in 1993 and since then, several alternative approaches to the gland have been described and a growing experience in this area achieved.? This early experience suggests that familiarity with the vascular relationships and anatomic variations for both right and left glands as well as advanced From the Department of Surgery, University of Washington, Seattle, Washington. Requests for reprints should be addressed to Mika N. Sinanan, MD, PhD, HSB BB-430, 1959 N.E. Pacific St., Box 356410, Seattle, Washington 981956410. Presented at the 83rd Annual Meeting of the North Pacific Surgical Association, Seattle, Washington, November 8-9, 1996. I
0 1997 by Excerpta All rights reserved.
Medica,
Inc.
AND
METHODS
From January 1994 to October 1996, 16 patients underwent laparoscopic adrenalectomy at the University of Washington. Indications for surgery were adrenal cortical adenoma (functional and nonfunctional), benign pheochromocytoma, and recurrent or untreatable Cushing’s disease. Contraindications were adrenal carcinoma and malignant pheochromocytoma. Malignant lesions were excluded from consideration because of the limited margins of resection and the potential difficulty with resection of these often vascular lesions. Localization of disease was carried out with a combination of radiographic and nuclear medicine studies, essential because of the narrow exploratory field available with the laparoscopic flank approach. Iodocholesterol scans4 helped confirm activity in 5 patients with small cortical adenomas poorly visualized by computed tomography (CT) while meta-iodo-benzyl-guanidine (MIBG) scans localized the increased catecholamine activity in all patients with pheochromocytoma. The CT scans were carried out in all patients to establish the anatomic relations of the involved gland, particularly useful in finding and isolating the adrenal on the left side. All pheochromocytoma patients received phenoxybenzamine starting at 10 mg per day and increasing to 20 to 30 mg per day until patients achieved a normal blood pressure. This treatment was carried out for a minimum of 10 days to allow the patient to equilibrate intravascular volume, minimizing the risk of acute hypertension or hypotension during anesthesia and manipulation of the adrenal gland. Tachycardia (pulse >lOO beats per minute from the beta agonist effects of circulating catecholamines) was treated with beta blockade as necessary, but for most patients this was not required. All patients received a mild cathartic as outpatients to avoid the presence of a full colon (hepatic or splenic flexure) in the surgical field. Surgical Technique All patients received arterial lines for monitoring of blood pressure. Intravenous alpha and beta agonist and antagonist drugs were immediately available for management of blood pressure swings in all patients with pheochromocytoma. Access to the retroperitoneum was made via the transperitoneal flank approach as described by Gagner et al.’ Patients were positioned on a bean bag with an axillary pad and the 0002-9610/97/$17.00 PII SOOO2-9610(96)00069-X
371
( LAPAROSCOPIC
ADRENALECTOMYlHORGAN
ET AL 1
operating room table extended at the waist to open the patient’s costopelvic space (Figure 1). The patient’s upper arm was suspended overhead with an airplane splint and both arm and hip were secured with wide tape or a belt. Rotating the patient into operative position before skin preparation and draping was important to assure proper adjustment of the arm and body position. The surgeon’s operative ports were placed on the costal margin in the mid clavicular (left hand) and mid axillary line (right hand) with the camera port between them and displaced back one hand’s breadth off the costal margin in the anterior axillary line (Figure 1, “x” skin marks). The righthand port was 12 mm in size for the possible use of a linear stapler, while the other two ports were 10 to 11 mm disposable ports. In most patients, an additional 5-mm port was placed later in the posterior axillary line off the costal margin for placement of an EndoKitner (U.S. Surgical Inc., Norwalk, CT) or other i-mm instruments to assist with retraction. For both right and left sides, the initial port placed was the camera port using an open technique to avoid injury to the liver on the right or a semiopen technique (elevation of the fascia for Verress needle placement) on the left, to minimize the risk of injury to the splenic flexure of the colon. Left Side On the left side, the adrenal gland is found off the medial, superior pole of the left kidney behind the splenlienal ligaments. Thus, the first step in the procedure is division of the lienorenal attachments, exposing Gerota’s fascia. The left adrenal gland is then found by opening Gerota’s fascia onto the superior pole of the kidney and dissecting medially and parallel to the ventromedial surface of the kidney. This maneuver is an important step since it orients the dissection away from the other glandular structure that might extend into the same area, namely, the tail of the pancreas. The adrenal gland is usually bright yellow and has a solid, platelike movement when pressed that distinguishes it from the surrounding fat that often obscures the margins of the gland. Once localized, arterial branches to the adrenal are divided superiorly (phrenic origin), medially (aortic origin), then inferiorly (renal artery origin) between clips or with cautery. Leaving areolar tissue attached to the adrenal facilitates manipulation of the gland as does use of an pretied loop (Fig-
Figure 1. Lateral decubitus for access to the left adrenal 372
THE
AMERICAN
position gland.
JOURNAL
and planned
OF SURGERY”
port
positions
VOLUME
173
Figure 2. Placement of a EndoLoop (Ethicon, Cincinnati, ventrolateral retraction of the right adrenal gland.
OH) for
ure 2), secured about the partially mobilized gland for subsequent posterior dissection. The left adrenal vein is usually posteriorly directed off the inferior pole of the gland, extending down to the left renal vein. Multiple vein branches are often present. Early division of the vein is often impossible, emphasizing the necessity for adequate preoperative pharmacological control in patients with a left-sided pheochromocytoma. Division of these vessels is often facilitated by use of the linear cutting device, or a right-angled multime stapler (Origin, Menlo Park, CA). The final dissection may require close cooperation between the anesthesiologist and surgeon since it is during this phase that most manipulation of the gland occurs. Right Side On the right, the liver must be mobilized laterally to include much of the bare area-attachment to the diaphragm. If the liver does not fall forward adequately to expose the medial aspect of the kidney and lateral aspect of the cava, an additional port and liver retractor may be necessary. This is usually placed between the scope and the surgeon’s righthand port. Following lateral mobilization of the liver, the adrenal is localized in Gerota’s fascia by opening the fascia and palpating for the platelike form of the gland off the medial superior aspect of the kidney. Next, the vena cava is exposed from just below the inferior liver margin superiorly and laterally, eventually demonstrating the inferior border of the right adrenal vein. Care must be taken to distinguish this from the renal vein or superior pole accessory renal veins, which may enter in close proximity. Following mobilization of the vein, it can be divided between multiple clips or with the linear cutter. Achieving adequate length to the vein is rarely a problem. Further dissection of the gland superiorly, behind the vein, and inferiorly exposes all arterial branches and eventually permits full mobilization of the gland. As with resection of the left gland, care to avoid tearing of the gland is critical since this can lead to unacceptable bleeding. Use of the pretied loop retractor is helpful in this regard. After full mobilization of the gland, placement of fascial closure sutures, and optionally a drain into the adrenal bed through the 5.mm port site, is followed by retrieval of the gland in an endoscopic bag, brought out through the 12mm port site to keep the gland intact. aAY
1997
RESULTS From January 1994 to October 1996, 16 patients underwent a laparoscopic adrenalectomy at the University of Washington Medical Center. These represent a consecutive series of referred patients. Contraindications to laparoscopic adrenalectomy include malignancy (absolute) or prior upper abdominal surgery on the involved side (relative) but, in practice, no patient referred for the procedure had a malignancy and no patient was denied laparoscopic treatment. Nine of these 16 patients were women and 7 were men. The mean age was 52 years (range 29 to 71). Of the 16 patients presented in this report, 3 underwent a bilateral adrenalectomy for otherwise uncontrollable Cushing’s disease and the rest had a unilateral benign pheochromocytoma (4 patients) or functional (cortisol or aldosterone secreting) adenoma ( 12 patients). Workup to localize the site of the disease included MIBG scans (3 studies), iodocholesterol scan (5 studies), and CT in all patients. Of the patients having unilateral procedures, 7 were on the left side and 6 on the right. In 3 patients undergoing right adrenalectomy, an extra port was necessary for liver retraction. The adrenal vein was controlled with clips alone in a majority of cases (16 patients) while a vascular 2.5-mm linear cutting instrument was used for the remaining 3 glands. Blood loss was minimal (
COMMENTS Since 1994, 19 adrenal glands have been removed using a laparoscopic flank approach. This represents an early experience, but for the most part, complications have been THE
AMERICAN
minor and manageable. All glands approached laparoscopically have been successfully resected without conversion to an open procedure. Based on this experience, we have derived several critical insights to successful completion of the procedure that deserve emphasis. First, proper placement of the port sites at the costal margin, appropriately oriented to liver or spleen and the adrenal gland, is essential to gaining safe access to the operative field. Second, the liver on the right and spleen on the left must be fully mobilized and allowed to fall under the influence of gravity, or retracted to the midline to fully expose the adrenal gland. Inadequate mobilization risks injury to those solid organs and compounds the difficulty of vascular control for both right and left glands. Third, the gland must be positively identified before extensive dissection or vascular structure ligation is carried out, a concept that is particularly critical on the left where the tail of the pancreas may be mistaken for the adrenal because of its proximity, glandular appearance, and consistency. Fourth, dissection of the gland surface, retaining areolar attachments for manipulation and retraction of the gland, is critical to avoid fracture, excessive bleeding, and potential tumor disruption. Fifth and last, closure of all lo-mm or greater port sites minimizes the risk of intercostal vessel bleeding as well as hernia formation. In general, localization and dissection of the right adrenal is more straightforward than the approach to the left gland but employment of these principles should increase the liklihood of success for the surgeon initiating practice with these techniques. Although this observational study suggests a favorable outcome with reduced length of stay and shorter recovery, it does not permit a direct comparison with patients treated by other methods, particularly the posterior, 12th-rib approach. However, other authors have performed this comparison and patient outcomes in our study compare favorably with their laparoscopic study groups. Duh et al” showed that patients undergoing laparoscopic flank and posterior approaches have a similar utilization of inpatient resources so the net benefit of the laparoscopic procedure was smaller incisions and avoidance of a rib resection. Proye et a1,7 in an experience with the open posterior approach, found a significantly longer mean hospital stay of 7.6 days. Prinz’ in 1995 analyzed his own patients and summarized the published data on open posterior and laparoscopic adrenalectomy, demonstrating less pain and an apparently reduced hospital stay with the laparoscopic approach. In aggregate, these published studies’,@ and our cohort included 74 patients treated via laparoscopic techniques. Although laparoscopic adrenalectomy is a technique that likely still warrants refinements in instrumentation and technical performance, this collective early experience, the obvious rapid recovery of our patients, and the enthusiasm of referring endocrinologists illustrates that it is a promising procedure that may well represent the next standard for management of nonmalignant adrenal tumors.
REFERENCES 1. Gagner M, Lacroix A, Prim R, et al. Early experience with laparoscopic approach for adrenalectomy. Surgery. 1993;114:11201125. 2. Mercan S, Seven toned adrenalectomy. JOURNAL
R, Ozarmagan S, et al. Endoscopic Surgery. 1995;118:1071-1076.
OF SURGERY@
VOLUME
173
MAY
retroperi-
1997
373
3. Gagner M, Lecroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s and pheuchromocytoma. NEJM. 1992;327:1033. 4. Yu KC, Alexander HR, Ziessman HA, et al. Role of preoperative iodocholesterol scintiscanning in patients undergoing adrenalectomy for Gushing’s syndrome. Surgery. 1995;118:981-987. 5. Gagner M, Lacroix A, Bolte E, et al. Laparoscopic adrenalectomy. The importance of a flank approach in the lateral decubitus position. Surg Endosc. 1994;8:135-138.
374
THE AMERICAN
JOURNAL
OF
SURGERY@
VOLUME
173
6. Duh Q, Siperstein A, Clark 0, et al. Laparoscopic adrenalectomy. Comparison of the lateral and posterior approaches. Arch Surg. 1996;131:870-875. 7. Proye C, Huart J, Cuvillier D, et al. Safety of the posterior approach in adrenal surgery: expertence in 105 cases. Surgq. 1993;114:1126-1131. 8. Prinz R. A comparison of laparoacopic and open adrenalectomies. Arch Surg. 1995;130:4899494.
MAY
1997