Laparoscopic Adrenalectomy:

1. Laparoscopic Adrenalectomy: The University of Kentucky Minimally Invasive Surgery Lab A General Overview By Taylor Baldwin

2. Adrenalectomy: Overview • Patient History, Work-up, and Diagnosis • The Laparoscopic Method • The Operating Room • Equipment • The Procedure • Complications and Post Operative Care

3. Patient History • A 54 year old male presents with the following symptoms: • An episodic headache • Excessive sweating • Tachycardia • Hypertension • Anxiety • Weight-loss • Elevated blood pressure

4. Workup • Initial symptoms fit the classic model of pheochromocytoma • A CT scan indicates a small (3cm) mass on the left adrenal gland. • Further biochemcial testing reveals elevated metanephrines (metabolite of catecholamines) in the urine, indicating an over secretion of catecholamines in the medulla of the adrenal gland. • This evidence leads to a strong indication of pheochromocytoma in the left adrenal gland.

5. Possible Methods for Treatment • Surgery (either open or laparoscopically) is the clear first choice treatment of these patients. • A combination alpha/beta blocker can be used to treat patients in an attempt to slow the heart rate. This treatment is often used with surgery as a preoperative treatment to prevent intraoperative hypertension. • Ultimately, the tumor needs to be removed.

6. Indications for the Laparoscopic Method • Functional adrenal cortical masses • Cortisol-secreting adenoma (Cushing’s adenoma) • Aldosterone-secreting adenoma (Conn’s disease) • Adrenal cortical hyperplasia (Cushing’s disease) • Functional adrenal medullary masses • Pheochromocytomas (tumor of medulla of adrenal gland) • Nonfunctional adrenal tumors • Adenoma (“incedentalomas”)

7. Contraindications for the Laparoscopic Method • Adrenal Carcinoma • Adrenal masses greater than 10 cm • Untreated Coagulopathies • Surgeon Inexperience • Surgical history of kidney or liver • Increase risk of adhesions making transperitoneal approach impossible • Make for much riskier dissections

8. Advantages of the Laparoscopic Method • Reduced wound morbidity • Shorter hospital stay • Easier/quicker return to normal activity • Reduced postoperative pain • Due to absence of large surgical wounds • Magnified view of operative field • Less blood loss

9. Open vs Laparoscopic Adrenalectomy Based on a 2004 study: http://linkinghub.elsevier.com/retrieve/pii/S1072751508000707

10. Patient Positioning • The patient is placed on the operating table slightly flexed at the waist in the right lateral decubitus position. • A cushion can be used under the lumber fossa on the contralateral side to open the operative field and help with trocar placement.

11. Team Placement • The primary surgeon stands facing the abdominal side of the patient • The second surgeon will also be standing on the abdominal side of the patient • The assisting nurse stands on the opposite side of the patient, facing the surgeon • The anesthesiologist/anesthesia tech typically stands at the head of the operating table on the side of the assistant

12. Team Placement (Continued) Primary Surgeon Anesthesiologist/ Anesthesia tech Assisting Nurse Assisting Surgeon

13. Equipment Placement • The operating room is centered around the operating table • The anesthetic equipment is typically placed at the head of the operating table • Monitors are set up on either side of the operating table for easy viewing • The instrument table is placed at the foot of the bed for easy access by the assisting nurse • Electrocautery and laparoscopic unit are placed where there is room

14. Equipment Placement (continued) Anesthetic equipment and monitor for viewing vital signs Electrocautery and laparoscopic unit typically placed in these locations Monitor used by surgeons to operate Monitor used by assistants to view surgery Instrument table placed at foot of bed

15. Instruments Used • Laparoscope • Typically a 30 degree laparoscope is used for this procedure • Dissectors • 5mm or 10mm grasper • Maryland Dissecting grasper • Cutting Devices • Laparoscopic scissors • Harmonic Scalpel • Hook Cautery • Other Instruments • Suction-irrigation Device • Extraction Bag • Clip Applier

16. Port Placement • The left adrenalectomy is an operation that requires three 10mm trocars and an optional fourth 5mm trocar • The 1st 10mm trocar is placed 2cm below and parallel to the costal margin • The 2nd 10mm trocar is placed under the 11th rib at the mid axillary line • The 3rd 10mm trocar is placed along the mid-clavicular line, lateral to the rectus muscle • The optional 5mm trocar is placed dorsally at the costovertebral angle

17. Port Placement (continued) 5mm trocar at the costovertebral angle 10mm trocar parallel to costal margin 10mm trocar along midclavicular line 10mm trocar on the midaxillary line

18. Procedure: Overview • Mobilize the colon • Divide the lienophrenic ligament • Divide the splenorenal ligament • Locate, clip, and cut the adrenal vein • Dissect the Lower aspect of the gland • Locate, clip, and cut the Inferior Adrenal Artery • Locate, clip, and cut the Middle Adrenal Artery • Locate, clip, and cut the Superior Adrenal Artery • Dissect the superior, posterior, and lateral aspects of the gland • Remove the Gland through an extraction bag

19. Procedure • Mobilization of the colon • This is done by cutting the lienocolic ligament • This will open the operating field and help to protect the colon from injury • Mobilization of the Spleen • This is achieved by dividing the lienophrenic ligament • This allows the surgeon to move the spleen and start to access the adrenal vein

20. Procedure • Division of the Splenorenal ligament • This is the ligament that is holding the spleen and kidney in close proximity • By removing this ligament, the surgeon is able to enter the proper field to find the adrenal vein • Locate, clip, and cut the Adrenal Vein • Once located, the surgeon should trace it back to the renal vein • Depending on the size of the vein, typically 3 clips are used proximally and 2 are used distally

21. Procedure • Dissect the lower aspect of the gland • Once the adrenal vein is removed, the lower aspect of the gland can be dissected • It is important to carefully watch for the inferior adrenal artery • Locate, clip, and cut the inferior adrenal artery • Once this artery is cut, it is possible to detach the inferior portion of the gland from the kidney

22. Procedure • Locate, clip, and cut the middle adrenal artery • Once this artery is cut it is possible to dissect the more medial aspects of the gland • Use the appropriate number of clips depending on the size of the artery • Locate, clip, and cut the superior adrenal artery • Once this artery is cut it is possible to dissect the more superior aspects of the gland • Again, use as many clips as necessary

23. Procedure • Dissect the superior, posterior, and lateral aspects of the gland • Now that the gland has been detached of its veins and arteries, it is possible to dissect it completely • Remove the gland with an extraction bag • It is important to watch out for and not harm other organs during this process

24. Possible Complications • Hemorrhage • Cause and Prevention • Correct any preoperative coagulopathies • Clip proximal portions of veins at least twice • Recognition and Management • Intraoperative hemorrhage identified by excessive bleeding and may require conversion to an open operation if hemostasis is not achieved • Postoperative hemorrhage is identified by monitoring vital signs and urine output overnight

25. Possible Complications (Cont.) • Damage to intraabdominal or retroperitoneal structures • Cause and Prevention • Knowledge of anatomy is key! • Trace veins to point of origin to be sure • Always know the location of spleen, liver, and pancreas • Recognition and Management • Damage to liver or spleen usually results in intraoperative or postoperative bleeding • Damage to pancreas can result in pancreatitis • Often these complications are self managed, but sometimes may require medical or surgical management

26. Post Operative Care • Pain medication given as required (typically only necessary for a few days) • Patient is allowed and able to ambulate (move about) on the same day • Liquid food intake is started the night of the procedure • Solid food intake may begin on the first postoperative day • The patient can leave the hospital on the second or third postoperative day