Overview
Definition:
Laparoscopic adrenalectomy is a minimally invasive surgical procedure to remove one or both adrenal glands using laparoscopic techniques
It involves making small incisions through which a camera and specialized instruments are inserted to perform the dissection and removal of the adrenal gland
This approach is now the preferred method for most adrenalectomies due to its advantages over open surgery.
Epidemiology:
Adrenalectomy is performed for a variety of benign and malignant adrenal tumors and conditions
The incidence of adrenal incidentalomas, often discovered incidentally on cross-sectional imaging, has increased, leading to more adrenalectomies
Pheochromocytomas account for about 2-5% of adrenal tumors, Cushing's syndrome for about 10%, and aldosteronomas for about 5-10%
Malignant adrenal neoplasms are rare.
Clinical Significance:
Laparoscopic adrenalectomy plays a crucial role in managing patients with symptomatic adrenal masses, hormone-secreting tumors (pheochromocytoma, Cushing's syndrome, Conn's syndrome), and incidentally discovered masses that are suspicious for malignancy or are functionally active
Successful removal can cure hormonal imbalances and potentially treat adrenal cancers, significantly improving patient outcomes and quality of life
It is a core competency for surgical residents preparing for DNB and NEET SS examinations.
Indications
Hormone Secreting Tumors:
Pheochromocytoma
Cushing's syndrome due to adrenal adenoma or hyperplasia
Primary aldosteronism (Conn's syndrome) due to adenoma
Adrenal virilization or feminization syndromes.
Adrenal Incidentalomas:
Malignant potential (size >4 cm, irregular margins, heterogeneous enhancement)
Functional activity (hormone secretion)
Rapid growth on follow-up imaging
Patient preference for definitive diagnosis/treatment.
Adrenal Cancer:
Primary adrenal cortical carcinoma
Metastatic disease to the adrenal gland (rarely resectable).
Other Indications:
Non-functioning adenomas >4 cm, or those causing mass effect
Adrenal cysts
Adrenal myelolipomas (large or symptomatic).
Preoperative Preparation
Hormonal Evaluation And Management:
Comprehensive endocrine workup to identify hormone excess
Alpha-adrenergic blockade (e.g., phenoxybenzamine) for pheochromocytoma for at least 7-14 days preoperatively, followed by beta-blockade if necessary
For Cushing's syndrome, adrenal enzyme inhibitors (e.g., metyrapone, ketoconazole) may be used
For aldosteronoma, appropriate medical management is continued.
Imaging Studies:
CT scan with contrast is essential for anatomical assessment, tumor size, and local invasion
MRI may be useful for complex cases or suspected venous invasion
Adrenal venous sampling may be required for bilateral adrenal hyperplasia or suspected aldosteronoma.
Anesthesia Considerations:
Careful anesthetic management, especially for pheochromocytoma, to avoid hypertensive crises during induction and manipulation
Invasive hemodynamic monitoring may be necessary
Postoperative steroid replacement needs to be planned.
Bowel Preparation And Prophylaxis:
Routine bowel preparation may be done
Prophylactic antibiotics and deep vein thrombosis prophylaxis are standard.
Procedure Steps
Patient Positioning And Trocar Placement:
The patient is typically positioned in the lateral decubitus or prone position
Three to four small incisions (0.5-1.5 cm) are made for trocars
A pneumoperitoneum is established, usually with CO2.
Transperitoneal Approach:
The most common approach
The colon is mobilized anteriorly to expose the adrenal gland
Key structures identified and dissected: renal vein, vena cava (for right adrenalectomy), aorta and renal vein (for left adrenalectomy), adrenal artery and vein.
Retroperitoneal Approach:
Less common, often used for smaller tumors or recurrent cases
Incision is made in the flank, and the retroperitoneal space is dissected to access the adrenal gland without entering the peritoneal cavity.
Dissection And Ligation Of Vessels:
The adrenal artery and vein are carefully identified and ligated using energy devices or clips
Dissection proceeds superiorly to the gland, carefully separating it from the surrounding fascia and retroperitoneal structures.
Adrenal Gland Excision And Extraction:
The adrenal gland is dissected free
It is then placed in an endoscopic retrieval bag and removed through one of the port sites, which may be slightly enlarged if necessary
Hemostasis is meticulously ensured.
Postoperative Care
Pain Management And Monitoring:
Adequate analgesia, often multimodal
Close monitoring of vital signs, fluid balance, and electrolytes
Pain is generally less than with open surgery.
Steroid Replacement:
For bilateral adrenalectomy or unilateral adrenalectomy in patients with pre-existing adrenal insufficiency, lifelong glucocorticoid and mineralocorticoid replacement is required
For unilateral adrenalectomy in patients with normal contralateral gland, temporary or no replacement may be needed, guided by endocrinological assessment.
Mobilization And Diet:
Early mobilization is encouraged
Patients can usually resume a regular diet once bowel function returns.
Discharge Criteria:
Afebrile, tolerating oral intake, adequate pain control with oral analgesics, and absence of significant complications
Most patients are discharged within 1-3 days.
Complications
Early Complications:
Bleeding (intraoperative or postoperative)
Injury to adjacent organs (spleen, pancreas, kidney, liver, bowel, major vessels)
Pneumothorax (especially with left adrenalectomy)
Adrenal crisis (hypotension, shock) due to inadequate steroid replacement or prolonged stress
Infection
Trocar site hernia.
Late Complications:
Adrenal insufficiency (if contralateral gland is compromised)
Adrenal remnant syndrome (hormonal recurrence from residual tissue)
Chronic pain
Adhesions
Recurrence of tumor (rare for benign lesions).
Prevention Strategies:
Thorough preoperative evaluation and management of hormonal status
Meticulous surgical technique with careful identification and ligation of vascular structures
Use of appropriate energy devices
Experienced surgical team
Careful postoperative monitoring and timely steroid replacement
Strict adherence to oncologic principles for malignant tumors.
Prognosis
Factors Affecting Prognosis:
The prognosis depends on the underlying pathology: excellent for benign, hormone-secreting tumors that are completely removed
guarded for adrenal cortical carcinoma, dependent on stage and completeness of resection
good for metastatic disease if the primary tumor is controlled.
Outcomes:
Laparoscopic adrenalectomy offers excellent outcomes with high success rates for tumor removal and cure of hormonal imbalances
Morbidity and mortality are significantly lower than with open adrenalectomy
Most patients return to normal activity within weeks.
Follow Up:
Postoperative follow-up includes hormonal assessment to confirm cure of hormone-secreting tumors and monitoring for adrenal insufficiency
Imaging follow-up is crucial for adrenal incidentalomas to detect recurrence or new lesions and for patients with adrenal cancer to monitor for metastatic disease or local recurrence
Follow-up schedules are guided by the specific pathology and risk stratification.
Key Points
Exam Focus:
Understand the indications for laparoscopic vs
open adrenalectomy
Know the specific preoperative medical management for pheochromocytoma, Cushing's syndrome, and Conn's syndrome
Identify critical vascular structures for right vs
left adrenalectomy
Recognize potential intra- and postoperative complications and their management.
Clinical Pearls:
Always ensure adequate alpha-blockade for pheochromocytoma before manipulating the gland to prevent hypertensive crisis
Left adrenalectomy may have higher risk of splenic injury
right adrenalectomy has higher risk of liver or vena cava injury
Prompt steroid replacement is vital postoperatively, especially after bilateral adrenalectomy.
Common Mistakes:
Inadequate hormonal preparation leading to perioperative crises
Incomplete dissection or failure to identify all vascular pedicles
Unrecognized injury to adjacent structures
Delayed or insufficient steroid replacement leading to adrenal crisis
Over-reliance on imaging alone for decision-making regarding incidentalomas.