Laparoscopic adrenalectomy, left and right

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Who: functioning, large or suspicious Three reasons to remove an adrenal. Function: a phaeochromocytoma with raised plasma or urinary metanephrines, an aldosterone-producing adenoma in primary hyperaldosteronism after adrenal venous sampling has lateralised it, or a cortisol-secreting adenoma with Cushing's syndrome. Size and appearance: an incidentaloma above four centimetres, or one of any size with a non-contrast density above 10 Hounsfield units and poor contrast washout, irregular margins or growth on repeat imaging, because the risk of adrenocortical carcinoma rises with size. And suspicion of malignancy: a primary adrenal carcinoma, which is removed open and en bloc, or a solitary adrenal metastasis in a patient whose primary is controlled. A non-functioning lesion under four centimetres with benign imaging is watched, not removed.
2. Preparation: alpha blockade and the endocrinologist Every adrenal is discussed with an endocrinologist and screened for function before it is removed, because the preparation differs. A phaeochromocytoma is alpha blocked with phenoxybenzamine or doxazosin for at least ten to fourteen days, the dose increased until the blood pressure is controlled and the patient is postural, with a high salt intake to refill the circulation; a beta blocker is added only after alpha blockade if there is tachycardia, never first, because unopposed alpha stimulation drives a hypertensive crisis. Cushing's syndrome means hydrocortisone cover from induction and a taper after, because the other adrenal is suppressed. Conn's means potassium corrected and spironolactone before surgery. The anaesthetist meets the phaeochromocytoma patient in advance and has an arterial line, magnesium, phentolamine or a nitroprusside infusion and noradrenaline drawn up.
   where it bites: a beta blocker started before the alpha blocker, or a phaeochromocytoma missed on screening, is a hypertensive crisis when the gland is touched.
3. Laparoscopic transperitoneal or retroperitoneal Most adrenals come out laparoscopically. The lateral transperitoneal approach, patient in the lateral position with the table broken, gives the familiar landmarks of the spleen, the colon, the kidney and the cava and room for a gland up to six centimetres or more; it is the standard in urological practice. The posterior retroperitoneoscopic approach, patient prone with the ports below the twelfth rib and the space held open at a higher pressure of about 20 millimetres of mercury, avoids the peritoneum and old adhesions and suits small glands and bilateral disease, at the cost of a small working space and unfamiliar landmarks. Open surgery is reserved for the suspected carcinoma, the gland above about eight centimetres, and the tumour that invades. The robot adds articulation for the retrocaval right gland.
4. Exposure on the left: spleen, pancreas and the upper pole Right lateral position, three or four ports below the left costal margin. The splenic flexure is taken down and the splenocolic, splenorenal and splenophrenic ligaments divided up to the diaphragm, so that the spleen and the tail of the pancreas roll medially with gravity and the assistant does not have to retract them. The plane behind the pancreas leads onto Gerota's fascia over the upper pole of the kidney. Gerota is opened over the upper pole and the medial border of the kidney, and the golden-orange adrenal is found in the fat above the upper pole, medial to it, distinguished from the fat by its colour and its firmness. The left renal vein is identified along the upper border of the hilum, because the adrenal vein runs down to it.
   where it bites: the tail of the pancreas lies across the field in front of the adrenal; a retractor or a hot instrument on it is a pancreatic fistula.
5. The adrenal vein first The left adrenal vein leaves the inferomedial aspect of the gland and runs down to enter the superior border of the left renal vein, often joined by the inferior phrenic vein on the way. It is found by following the renal vein medially along its upper border, dissected free with the hook or the bipolar for a centimetre, and taken between clips before the gland is handled, so that catecholamines released by manipulation cannot reach the circulation. The anaesthetist is told when the vein is about to be clipped, because the blood pressure falls when it is, and the noradrenaline is started as the clip goes on. In a phaeochromocytoma the gland is handled as little as possible before this point, and the vein is the first thing sought.
   where it bites: traction on the gland before the vein is clipped pours catecholamines into the circulation; the pressure hits 250 and the anaesthetist has no warning.
6. Mobilising the gland With the vein clipped the gland is lifted by the fat around it, never grasped directly because it is friable and tears, and the arterial supply is taken as it is met: small branches from the inferior phrenic artery above, the aorta medially and the renal artery below, sealed with the bipolar or the ultrasonic shears clear of the gland. The medial border is freed from the crus and the aorta, the superior pole from the diaphragm, and the inferior border from the upper pole of the kidney, outside the capsule and with a cuff of fat so that a suspicious lesion is not breached. The dissection stays close enough to avoid the pancreas and the splenic vessels, which lie a centimetre or two in front.
7. Extraction in a bag The gland is placed in a retrieval bag as soon as it is free, the bag closed, and delivered through the enlarged camera port or a port site extended for a larger gland, intact and unmorcellated, so that the pathologist has the whole gland and its capsule and so that nothing is spilt. The bed is inspected at low pressure for bleeding from the phrenic branches and the renal vein stump, and the spleen and the pancreatic tail are looked at before the ports come out. A drain is not usually needed unless the pancreas was handled. The specimen is orientated and weighed, and in a phaeochromocytoma the genetics are requested, because a third or more are hereditary.
8. The right side: the cava and the short vein Left lateral position, the ports below the right costal margin, and the right lobe of the liver retracted upward by a fan or a Nathanson through an epigastric port after the triangular ligament is divided. The duodenum is kocherised if it lies over the field. The lateral border of the cava is found and followed upward, and the adrenal sits behind and lateral to it above the right renal vein, partly retrocaval. The right adrenal vein is short, a centimetre or less, wide, and enters the posterolateral cava directly; it is found by dissecting the medial border of the gland off the cava from below upward, and clipped twice on the caval side with the cava seen throughout. The gland is then mobilised as on the left.
   where it bites: the right adrenal vein torn from the cava is a hole in the cava that retracts; it is clipped under vision with the cava seen, or the operation is opened.
9. After A phaeochromocytoma patient goes to a monitored bed: hypotension in the first day from the loss of catecholamines and the residual alpha blockade is treated with fluid and noradrenaline, and hypoglycaemia is looked for because the insulin suppression is gone. Plasma metanephrines are repeated at two to six weeks and then yearly for life. A Cushing's adenoma patient is on hydrocortisone, tapered over months while the suppressed contralateral adrenal recovers, with a morning cortisol guiding withdrawal. A Conn's patient stops spironolactone, has the potassium checked, and is warned that hypertension improves but may not resolve. After bilateral adrenalectomy the patient has hydrocortisone and fludrocortisone for life with a steroid card and sick day rules. Every patient sees the endocrinologist with the histology.

Complications and immediate saves

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FRCS viva questions

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Evidence and guidance