Laparoscopic adrenalectomy for pheochromocytoma: comparison with open adrenalectomy and comparison of laparoscopic surgery for pheochromocytoma versus other adrenal tumors

OBJECTIVE: To compare the efficacy of laparoscopic adrenalectomy for pheochromocytoma with that of conventional open adrenalectomy for pheochromocytoma and laparoscopic surgery for other adrenal tumors. PATIENTS AND METHODS: Fifty-four patients with adrenal tumors, including 10 cases of pheochromocytoma, 18 cases of Cushing's syndrome, 20 cases of primary aldosteronism, and 6 cases of nonfunctioning tumors, were evaluated. A historical group of 7 consecutive patients who underwent conventional open adrenalectomy for pheochromocytoma was also studied. RESULTS: Laparoscopic adrenalectomy for pheochromocytoma was successful in 9 of the 10 patients. There was no difference in tumor size, operation time, estimated blood loss, or occurrence of hypertensive episodes during surgery between patients treated with laparoscopic procedures and those treated with open surgery. However, the number of days to first postoperative oral feeding and first ambulation, length of hospitalization, and number of patients requiring parenteral analgesics were significantly smaller after laparoscopic surgery than after open surgery. There was no significant difference in operation time, estimated blood loss, incidence of intraoperative complications, or postoperative recovery between patients who underwent laparoscopic adrenalectomy for pheochromocytoma and those who underwent laparoscopic surgery for other adrenal lesions. CONCLUSIONS: Laparoscopic adrenalectomy does not increase the specific risks associated with surgery for pheochromocytoma. It is a minimally invasive alternative to conventional open adrenalectomy.     

Laparoscopic adrenalectomy: Akita University experience

We performed 52 laparoscopic adrenalectomies between January 1997 and March 2003. In 51 patients, adrenal tumors were successfully removed laparoscopically. In one patient, the laparoscopic procedure was converted to open surgery because of insufflator's trouble and hemorrhage. Perioperative blood transfusion was required in two patients; one for intraoperative and another for postoperative bleeding. We compared laparoscopic adrenalectomy with conventional open surgery which had been performed in our clinic before the laparoscopic adrenalectomy era. The mean operative time of the laparoscopic adrenalectomy (187 +/- 59 min) was not significantly longer than that of the open surgery (193 +/- 49 min). The mean estimated blood loss of laparoscopic adrenalectomy (75 +/- 145 g) was significantly less than that of the open surgery (438 +/- 447 g). Time to oral intake and ambulation for laparoscopic adrenalectomy were significantly earlier than those of the open surgery. Operation time was significantly shortened as the experience of this surgery was accumulated. The results of our experience support the concept that laparoscopic adrenalectomy is safe and is a standard treatment for surgical treatment of adrenal tumors.     

Comparison of laparoscopic versus open surgery for adrenal tumor

We performed 25 laparoscopic adrenalectomies for adrenal tumor between January 1998 and December 2000. In 23 cases, adrenal tumors were successfully removed laparoscopically, but in 2, the laparoscopic procedure was converted to open surgery because of liver injury and endoscopically uncontrolled bleeding at the renal hilum. Postoperative complications, involving retroperitoneal hematoma, hypercapnia, and wound infections, could be managed without surgical treatment. We compared laparoscopic adrenalectomy with conventional open surgery, which had been performed for 24 adrenal tumors in our clinic. The mean operative time for the laparoscopic adrenalectomy (228.8 +/- 65.5 minutes) was significantly longer than those for the open surgery (156.0 +/- 43.8 minutes). The estimated blood loss (82.3 +/- 125.4 g) was significantly less than those for the open surgery (210.8 +/- 167.7 g), and the laparoscopic adrenalectomy had significant advantages in lessening postoperative analgesic requirements, shortening postoperative recovery period, and preserving good physical appearance. Therefore, we conclude that the laparoscopic adrenalectomy is a less invasive surgery, and is acceptable as a standard operation for adrenal tumors.     

Laparoscopic operative technique for adrenal tumors.

BACKGROUND AND OBJECTIVES: Laparoscopy has acquired an unquestionable position in surgical practice as a diagnostic and operative tool. Recently, the laparoscopic approach has become a valuable option for adrenalectomy. This paper reports, in detail, our experience of laparoscopic adrenalectomy performed for adrenal tumors. METHODS: We performed 12 laparoscopic adrenalectomies from October 29, 1997 to October 31, 1998. The technique of laparoscopic adrenalectomy is described thoroughly in all relevant details for either left or right-sided adrenal lesions. RESULTS: The presented technique of laparoscopic adrenalectomy in all 12 cases provided good and relatively simple exposure of the immediate operative area. All relevant vascular elements were safely controlled, adrenal tumors could be successfully removed, and adequate hemostasis was achieved. No intraoperative or postoperative complications were observed. CONCLUSIONS: Laparoscopic adrenalectomy is a safe alternative to open surgery and is preferred for most patients because of shorter postoperative hospital stay and less postoperative discomfort.     

Laparoscopic adrenalectomy. A new standard of care.

OBJECTIVE: The authors review their experience with laparoscopic adrenalectomy in patients with benign adrenal neoplasms. Efficacy, safety, and cost effectiveness of the procedure are examined. BACKGROUND: Laparoscopic adrenalectomy is replacing open adrenalectomy in some medical centers as the standard surgical approach for uncomplicated tumors. However, laparoscopic adrenalectomy often is considered more difficult and more expensive than traditional "open" surgery. METHODS: Perioperative and postoperative records as well as hospital charges from the first 19 patients undergoing laparoscopic unilateral adrenalectomies at the authors' medical institutions were examined and compared with 19 patients who underwent open unilateral adrenalectomies. RESULTS: None of the 19 patients undergoing unilateral laparoscopic adrenalectomy required conversion to open adrenalectomy. Mean operative times as well as total hospital charges were similar in those patients undergoing either laparoscopic or open adrenalectomy. However, the morbidity and postoperative length of hospital stay were significantly less in those patients undergoing laparoscopic adrenalectomy. CONCLUSIONS: Laparoscopic adrenalectomy can be performed safety and with the benefits associated with minimally invasive surgery. In addition, the procedure is cost effective. These factors suggest that laparoscopic adrenalectomy should be the preferential surgical technique for benign adrenal disease.     

Comparison of laparoscopic and open adrenalectomy--a Singapore experience

OBJECTIVE: We present our experience with laparoscopic adrenalectomy for benign adrenal diseases and compare clinical outcomes with the conventional open approach. METHODS: Between 1990 and 2001, two consecutive series of patients who underwent adrenalectomy for small, benign adrenal diseases were reviewed retrospectively. Patients with large tumours(> 7 cm), cancer and phaeochromocytoma were excluded. Fifty-eight patients underwent laparoscopic adrenalectomy and 48 patients had open surgery for benign adrenal diseases. Perioperative and postoperative records of both approaches were reviewed. RESULTS: The two groups were comparable in terms of patient age, sex, weight and side of lesion.The common indications for surgery were Conn's syndrome and Cushing's syndrome. The sizes of tumour were comparable between the laparoscopic and open groups (mean, 2.1 cm vs 2.4 cm). Despite the longer operating time (mean, 128 minutes vs 87 minutes), the postoperative morbidity, parenteral analgesic requirement and length of postoperative hospital stay (3.2 days vs 7.2 days) were less inpatients undergoing laparoscopic adrenalectomy. Patients also enjoyed earlier return to oral intake and ambulation. There were fewer complications in the laparoscopic group. There was no conversion to open surgery. CONCLUSION: Laparoscopic adrenalectomy is safe and has become the treatment of choice for small, benign adrenal lesions at our institution.     

Laparoscopic adrenal surgery

Summary. Minimally invasive adrenalectomy is now an accepted alternative to conventional adrenalectomy. As in open surgery, several different endoscopic approaches to the adrenal glands have been described. In principle, one must distinguish between the laparoscopic and the retroperitoneoscopic access. All adrenal tumors – pheochromocytomas included – except adrenal carcinomas can be removed endoscopically. However, the use of these techniques is limited in patients with particularly large tumors. The results reported to date are convincing. Only limited data are available as yet to compare conventional and endoscopic adrenalectomy. Because adrenal diseases requiring surgery are rare, endoscopic adrenalectomy is an operation that, for the present, will be limited to centers with a particular interest in laparoscopic and endocrine surgery.      

Complications of laparoscopic adrenalectomy in 75 patients treated by the same surgeon.

OBJECTIVE: We analyzed the complications of endoscopic adrenalectomy. METHODS: We retrospectively reviewed the operative and postoperative complications among 75 patients with adrenal tumors who underwent endoscopic adrenalectomy by the same surgeon. RESULTS: Five patients (6.7%) were converted to open surgery. Of these, there were 2 with metastatic adrenal carcinoma, and 1 with adrenal tuberculosis. A total of 21 patients (28%) had 24 complications (32%). There was no mortality. As for access and pneumoperitoneum-related complications, 5 cases of subcutaneous emphysema and 3 of radiating shoulder pain occurred. Intraoperative complications included 2 cases of vascular injury, 2 of organ injury, and 4 of massive bleeding (>500 ml). Postoperative complications included 2 cases of mild paralytic ileus, 2 asthma, and 1 each of angina, wound infection, retroperitoneal hematoma, and contralateral atelectasis. Except for the patients with adrenal malignancy and adrenal tuberculosis, 71% of the complications occurred among the initial 25 patients with laparoscopic adrenalectomy and 80% occurred in the initial 10 retroperitoneoscopic patients. CONCLUSION: Although endoscopic adrenalectomy is a valuable alternative to open surgery, it should be done by a skilled laparoscopist in patients with adrenal inflammatory lesions or malignancy. Careful patient selection and correct choice of surgical approach according to the tumor size and the patient's condition are the most important points for avoiding the complications of laparoscopic adrenalectomy.     

Applicability of laparoscopic adrenalectomy in a prospective study in 150 consecutive patients

HYPOTHESIS: Within a decade, laparascopic adrenalectomy has become the new "gold standard" for the surgical treatment of most adrenal lesions. Designed as a single-center project focused on patients with adrenal lesions, this study should provide an indication of the number of patients requiring surgery who can safely undergo laparoscopy, after consideration of such selection criteria as tumor size and benign or malignant lesion status at magnetic resonance imaging. Furthermore, the access-related complications were analyzed. DESIGN: According to a prospective protocol, 150 consecutive patients selected for adrenal surgery were assigned to transperitoneal endoscopic or open adrenalectomy. SETTING: University hospital section of endocrine surgery. RESULTS: One hundred two patients (68%) were selected for a laparoscopic approach that had to be converted to open surgery in 5 patients (5%). Two malignant cortisol-secreting lesions were operated on laparoscopically because of their small size and benign appearance at magnetic resonance imaging. During histological examination, 14 (29%) of 48 patients assigned to transperitoneal open adrenalectomy had lesions deemed malignant (16 [11%] of 150 patients). The laparoscopic group had significantly fewer complications (9%) than did the open group (21%; P =.04). CONCLUSIONS: By applying defined selection criteria for the treatment of adrenal lesions, transperitoneal endoscopic adrenalectomy can be a safe procedure and may be performed in at least two thirds of patients. The choice of endoscopic or open approach in larger tumors should depend on the results of preoperative imaging studies and the endocrine surgeon's experience in endoscopic adrenal surgery.     

Adrenalectomy: indications and options for treatment

The history of adrenal surgery is longstanding. Firstly described in 1889 by Thornton, the open adrenalectomy has been for decades the only surgical approach to adrenal diseases. Nowadays, instead, several approaches to adrenal glands have been described in the literature, such as laparoscopic adrenalectomy, robotic-assisted procedure and single-incision technique. Actually, laparoscopic adrenalectomy is considered as the gold standard treatment for adrenal lesions. In fact, all functional tumors, including pheochromocytoma, are candidates for a laparoscopic approach in the absence of other contraindications. In the adrenal gland surgery, it is important to consider that a multidisciplinary approach which comprises surgeons, anesthesiologists, endocrinologists, and oncologists plays an important role in the management of patients and that the success of the procedure is related also to surgeon experience and hospital volume. This review aims to discuss the indications for adrenalectomy and to describe the different techniques options for the adrenal gland surgery.     

肾上腺外科疾病手术方式的选择

与传统的开放手术相比,腹腔镜肾上腺切除术具有手术创伤小、出血少、术后疼痛轻、住院时间短、切口并发症少、康复快等优点。随着腹腔镜手术的普及,腹腔镜肾上腺切除术由最初的选择性手术逐步成为标准的手术,目前已经成为肾上腺外科首选的手术方法。对于较大的肾上腺肿瘤或恶性肿瘤,腹腔镜手术的作用还存在一定争议。本文就各种肾上腺疾病进行外科治疗时腹腔镜手术与开放手术的选择进行讨论。     

Laparoscopic adrenalectomy for pheochromocytoma

Laparoscopic adrenalectomy has become the standard technique for the surgical removal of the adrenal gland for functional adrenal tumors including aldosteronoma, glucocorticoid, and androgen/estrogen-producing adenomas. Many laparoscopic surgeons also think that for small to moderately sized pheochromocytomas, the laparoscopic approach is as safe and effective as the open technique. Several physiologic considerations specific to pheochromocytoma must be addressed before and during surgery regardless of the operative approach. The advantages of laparoscopic adrenalectomy over open adrenalectomy remain the same for pheochromocytomas as for other pathologic conditions of the adrenal gland. These include a shorter length of stay, a decrease in postoperative pain, a shorter time to return to preoperative activity level, and improved cosmesis.     

Applicability and outcome of laparoscopic adrenalectomy

Laparoscopic adrenalectomy has been shown to be as safe and effective as conventional open surgery for small and benign adrenal lesions. With increasing experience with laparoscopic adrenalectomy, this approach has become the procedure of choice for the majority of patients requiring adrenalectomy, although careful selection of patients accounts for the favourable clinical outcome observed. Laparoscopic adrenalectomy was adopted as the procedure of choice for patients requiring adrenalectomy in our institution in 1995. From 1995 to 2001, 82 consecutive patients underwent adrenalectomies for various adrenal pathologies. The laparoscopic approach was used for 60 of these patients, whose selection was based on the preoperative size and/or benign nature of the adrenal lesion. The procedures were successfully performed in 57 patients (54 unilateral, 3 bilateral), while three (5%) patients required conversion to open surgery. There was no hospital mortality and complications occurred in two (3%) patients. The median hospital stay was 3 days (range, 2-8 days) and analgesic requirement was minimal. Laparoscopic adrenalectomy can be done for all patients with small and benign adrenal pathologies, and has become the gold standard for patients undergoing adrenalectomies. When successfully performed, the laparoscopic approach offers the advantages of a minimally invasive procedure with improved patient comfort and faster postoperative recovery.     

Laparoscopic adrenalectomy: Troublesome cases

Among 143 cases of laparoscopic adrenalectomy carried out from 1993 to the present, 13 patients in whom the surgical manipulation presented problems were examined. Problems occurred due to the condition of the adrenal tumors themselves in six patients, whereas problems occurred due to the operative history in four patients. There were three patients with no operative history but with strong intraperitoneal adhesion. In patients with a history of laparotomy in other fields such as open cholecystectomy, gastrectomy or colostomy, operations were possible in most patients by examining the trocar site preoperatively. Patients with strong adhesion even without a history of surgery could be handled by full separation of the adhesion during surgery. In patients with bleeding in the adrenal tumors, large adrenal tumors, or tumors impacted in the liver, methods such as changing the sequence of separation procedures were required. In patients with a history of renal subcapsular hematomas due to extracorporeal shock wave lithotripsy (ESWL), it was not possible to understand the conditions of adrenal or perinephritic adhesion in preoperative imaging diagnosis, but resection was possible by changing the order of separation procedures and by using optimal instruments and devices. As with any surgery, including open surgeries, it is necessary to obtain knowledge on how to deal with variations in laparoscopic adrenalectomy to assure safe outcomes and to always consider effective methods for coping with unexpected difficulties.     

Laparoscopic adrenalectomy for isolated adrenal metastasis.

BACKGROUND: Laparoscopic adrenalectomy is accepted by many as the standard of care for the majority of adrenal masses less than 8 cm. The question exists whether laparoscopic removal of metastatic lesions to the adrenal is more difficult than laparoscopic removal of primary adrenal lesions. METHODS: We performed a retrospective analysis of all laparoscopic adrenalectomies performed at a single institution from 1998 to 2001, comparing laparoscopic adrenalectomies for primary lesions of the adrenal gland versus isolated metastatic lesions to the adrenal gland. RESULTS: Fourteen laparoscopic adrenalectomies were attempted, 10 for primary disease and 4 for metastatic disease. All 10 laparoscopic procedures were completed successfully for primary disease (average operative time=218 minutes, average tumor size=4 cm, median hospital stay=2 days). Only one of the 4 laparoscopic adrenalectomies for metastatic disease was completed successfully (average operative time=332 minutes, average tumor size=7.3 cm, median hospital stay=2 days). No major complications occurred in either group. CONCLUSIONS: We feel laparoscopic adrenalectomy is the preferred approach for primary adrenal masses less than 8 cm. Based on our experience and a review of the literature, isolated metastatic lesions to the adrenal gland appear less amenable to laparoscopic removal than do primary lesions of the same size.     

Laparoscopic adrenalectomy (LA): keys to success: correct surgical indications, adequate preoperative preparation, surgical team experience

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the surgical procedure of choice for the treatment of most adrenal lesions. Controversy still remains about the treatment for primary and secondary malignant lesions and for pheochromocytoma. MATERIALS AND METHODS: From September 1997 to December 2005, 77 patients were operated on for adrenal tumors in a single center. Three patients had bilateral lesion for a total of 80 adrenalectomies. Selection criteria for laparoscopic treatment included benign characteristics of the lesions regardless of size and absence of virilization syndrome. A multidisciplinary approach was used for adequate preparation of patients with functional lesions. Fifty-five patients were eligible for LA and 22 for open surgery. RESULTS: Mean operative time was 142 minutes (range 45 to 240) in the laparoscopic group (53 patients) and 161 minutes (range 90 to 300) for the open group (24 patients). In 2 patients (4%) conversion to open procedure was necessary for intraoperative bleeding. Laparoscopic surgery in patients with pheochromocytoma was associated with a better intraoperative hemodynamic stability. CONCLUSIONS: LA is the treatment of choice for benign adrenal tumors regardless of size. Appropriate selection of patients, adequate preoperative preparation of patients with functional lesions and expertise in adrenal surgery and advanced laparoscopic skills are necessary to allow reduction of perioperative morbidity and early recovery.     

Laparoscopic partial adrenalectomy for recurrent pheochromocytoma after open partial adrenalectomy in von Hippel-Lindau disease

BACKGROUND AND PURPOSE: Unilateral total adrenalectomy is the standard treatment for benign unilateral adrenal tumors. Partial adrenalectomy has to be considered for bilateral adrenal tumors. Recently, our group has reported the feasibility of unilateral and bilateral partial adrenalectomy by means of laparoscopy. Now, we present a case of recurrent pheochromocytoma after open bilateral adrenalectomy and demonstrate that laparoscopic cortex-sparing surgery is feasible for a recurrence after open surgery. Case Report: At the age of 10 years, a boy was found to have bilateral adrenal pheochromocytoma and was treated by open bilateral partial adrenalectomy. Eight years later, the patient presented with palpitation, sweating, and severe hypertension. Investigations biochemically and radiologically demonstrated functional recurrent pheochromocytoma in the left adrenal gland. Genetic studies confirmed mutation of the von Hippel-Lindau (VHL) gene. The patient was prepared for surgery preoperatively by phenoxybenzamine and metropolol. The surgery was performed as planned, and the normal adrenal tissue was spared. The patient had an uneventful postoperative course. His blood pressure was normal on the day of discharge. CONCLUSIONS: In a specialized center with experienced laparoscopic surgeons, laparoscopic partial adrenalectomy for recurrent pheochromocytoma is feasible even after previous open surgery on the ipsilateral adrenal gland. Adrenal-sparing surgery is indicated in hereditary syndromes such as VHL and MEN II to avoid the problems of life-long steroid replacement. Recurrences have to be expected, but further surgery may be less difficult by the previous laparoscopic approach.     

Hand-assisted laparoscopic adrenalectomy: an alternative minimal invasive surgical technique for the adrenal gland

Background: Presently the surgical approach to the adrenal gland is in a state of flux. While the traditional approach to the adrenal gland has been the open transabdominal technique, more recently laparoscopic approaches, particularly via the transabdominal route, have increasingly been utilized. However, laparoscopic intervention for the adrenal gland can be problematic in certain circumstances, particularly for large adrenal masses and in instances of adrenal malignancies. Methods: In this report we describe the use of hand‐assisted laparoscopic adrenalectomy as an alternative minimal invasive surgical approach to the adrenal gland. Hand‐assisted laparoscopic adrenalectomy using the HandPort system (Smith & Nephew, Sydney, Australia) was undertaken in three patients requiring adrenalectomy for mass lesions including one patient with Conn's syndrome. Results: In all three cases, surgery proceeded promptly and uneventfully. In the present paper, the details of the technique of hand‐assisted adrenalectomy are described. This is the first report in the world literature of this new technique for the adrenal gland. Conclusions: Hand‐assisted laparoscopic adrenalectomy is an easily performed technique, which can be completed within a short operative time span and which has the advantage of providing intraoperative tactile localization for the adrenal gland. It may be particularly applicable for large adrenal tumours, yet only involves the performance of a small abdominal incision. Postoperative recovery is comparable with that reported for the laparoscopic‐only technique. Hand‐assisted adrenalectomy is a new technique which has great potential and which warrants further evaluation.     

Laparoscopic bilateral adrenalectomy following failed hypophysectomy

Background: Laparoscopic adrenalectomy has recently been shown to be a safe and effective means of treating adrenal pathology with much lower morbidity than the traditional approach. The majority of reports in the literature involve removal of adrenal tumors. Although open bilateral adrenalectomy has been utilized for persistent Cushing's syndrome following attempted hypophysectomy, there is little data available describing the application of laparoscopic adrenal surgery to this problem. Methods: Four patients with persistent Cushing's syndrome after attempted treatment with hypophysectomy underwent laparoscopic bilateral adrenalectomy at our institution. One procedure was done transabdominally in the supine position. Three procedures were done transabdominally using sequential lateral decubitus positions. Results: All procedures were completed laparoscopically. The mean operative time was 4.6 h (range 3.9–5.25). Repositioning and reprepping the patients resulted in a slight increase in operative time, but visualization was improved using the lateral decubitus position. Average blood loss: 156 cc (range 50–300). One patient required early reoperation for bleeding from the left adrenal bed, which was controlled laparoscopically. Three patients were eating the following day and were discharged on postoperative days 1, 2, and 5. The fourth patient remained hospitalized for 18 days due to problems unrelated to surgery. After a mean follow-up of 10 months, all patients have done well and have no clinical or biochemical evidence of recurrent disease. Conclusion: Our clinical experience indicates that laparoscopic bilateral adrenalectomy is a viable treatment option for Cushing's syndrome following failed hypophysectomy. Received: 29 March 1996/Accepted: 12 June 1996     

Laparoscopic adrenalectomy in adrenal carcinoma

There is general agreement on the suitability of the laparoscopic approach for benign adrenal lesions against open procedures because of the efficacy and less morbidity. For suspected adrenal malignancies laparoscopic use is controversial. We report our experience in 6 cases of laparoscopic adrenalectomy in patients with the suspicion of adrenal malignancy confined in the gland. In medium a follow up of 24 months (range 12 to 48 months) we observed no recurrences. We concluded that in a suspected adrenal malignancy organ confined laparoscopic adrenalectomy presents the advantage compared with open surgery of reduced morbidity and similar results in the follow up of the patient.