Overview
Definition:
Posterior retroperitoneoscopic adrenalectomy (PRA) is a minimally invasive surgical technique for the removal of adrenal gland tumors or the entire adrenal gland
It is performed through a posterior flank incision, accessing the retroperitoneal space without entering the peritoneal cavity.
Epidemiology:
Adrenal incidentalomas are found in 3-10% of abdominal imaging studies
While most are benign, a small percentage are malignant or hormonally active
PRA is indicated for a significant proportion of these, especially when less than 6-8 cm and without evidence of invasion
The incidence of adrenalectomies varies based on local referral patterns and expertise.
Clinical Significance:
PRA offers significant advantages over open adrenalectomy, including reduced postoperative pain, shorter hospital stays, faster recovery, and improved cosmesis
It is the preferred approach for many benign and some malignant adrenal lesions, allowing for safe and effective tumor removal while minimizing patient morbidity
Understanding PRA is crucial for surgical residents preparing for DNB and NEET SS examinations due to its increasing prevalence in clinical practice.
Indications
Hormonally Active Tumors:
Pheochromocytoma
Cushing's syndrome (adenoma, carcinoma)
Primary aldosteronism (Conn's adenoma)
Adrenal virilization
Non-functioning tumors >4 cm or showing growth on follow-up.
Non Hormonally Active Tumors:
Incidentalomas > 4 cm
Tumors suspicious for malignancy (e.g., irregular margins, calcifications on imaging)
Tumors with rapid growth
Patient preference for minimally invasive approach when technically feasible.
Contraindications:
Large adrenal masses (> 6-8 cm, depending on surgeon experience)
Suspected adrenal cortical carcinoma with invasion into adjacent structures
Significant retroperitoneal adhesions from prior surgery
Uncorrected coagulopathy
Severe cardiopulmonary disease precluding pneumoperitoneum or Trendelenburg positioning (though PRA may be suitable in some cases).
Preoperative Preparation
Hormonal Assessment:
Comprehensive endocrine workup to rule out hormonally active tumors
For pheochromocytoma: alpha-blockade (e.g., phenoxybenzamine, prazosin) initiated 1-2 weeks preoperatively, followed by beta-blockade if tachycardia is present
For Cushing's: ketoconazole or metyrapone for cortisol suppression
For aldosteronism: correction of hypokalemia.
Imaging Evaluation:
Contrast-enhanced CT scan of the abdomen and pelvis to delineate tumor size, location, relation to surrounding structures (renal vein, IVC, aorta, kidney), and presence of invasion or metastasis
MRI may be used for better soft tissue characterization
Chest X-ray or CT scan to rule out pulmonary metastases.
Anesthesia Considerations:
General anesthesia with controlled ventilation
Careful hemodynamic monitoring, especially for pheochromocytoma, due to potential for catecholamine surges
Arterial line for continuous blood pressure monitoring
Central venous access
Postoperative pain management plan.
Procedure Steps
Patient Positioning:
Patient is placed in the lateral decubitus or prone position
The ipsilateral flank is elevated with a roll or beanbag to widen the intercostal spaces and facilitate access to the retroperitoneum.
Incisions:
Typically, three or four small incisions (0.5-1.5 cm) are made along the flank, parallel to the intercostal spaces
The most inferior incision is usually used for instrument insertion, while a superior incision may be used for the camera
A slightly larger incision may be made for specimen retrieval.
Dissection And Identification:
The retroperitoneal space is accessed and dissected using blunt and sharp instruments, often with CO2 insufflation (though not always required for PRA)
The adrenal gland and tumor are identified
The kidney, spleen (left side), liver (right side), diaphragm, and major vessels (aorta, IVC) are key landmarks.
Vascular Control And Excision:
The adrenal vein is identified, ligated, and divided early
This is a critical step to prevent tumor manipulation and potential catecholamine release in pheochromocytoma
The adrenal artery is then ligated
The gland is carefully dissected free from surrounding structures, taking care to avoid injury to the kidney, diaphragm, or large vessels
The specimen is placed in an endoscopic retrieval bag.
Closure:
After confirming hemostasis, the specimen is removed
The small incisions are closed with absorbable sutures for deeper layers and skin sutures or adhesive strips for the skin.
Postoperative Care
Pain Management:
Multimodal analgesia including patient-controlled analgesia (PCA), oral opioids, and NSAIDs
Regional blocks may be considered
Pain is generally less severe than with open surgery.
Monitoring:
Hemodynamic stability, urine output, respiratory status, and pain levels
Electrolyte balance, especially after removal of an aldosterone-producing adenoma
For pheochromocytoma, monitor for residual hypertension or postural hypotension
Vigilance for signs of adrenal insufficiency or hemorrhage.
Mobilization And Diet:
Early ambulation is encouraged
Patients can typically resume a regular diet as tolerated
Discharge is usually within 1-3 days, depending on patient recovery and absence of complications.
Adrenal Insufficiency:
For patients undergoing bilateral adrenalectomy or total unilateral adrenalectomy for bilateral disease, postoperative corticosteroid replacement (hydrocortisone) is essential
Monitor for symptoms of adrenal crisis (fatigue, nausea, vomiting, hypotension).
Complications
Intraoperative Complications:
Bleeding from adrenal vein or surrounding vessels
Injury to adjacent organs (kidney, spleen, liver, pancreas, diaphragm, bowel)
Pneumothorax or hemothorax
Gas embolism
Conversion to open surgery due to technical difficulty or uncontrolled bleeding.
Postoperative Complications:
Pain
Wound infection or seroma
Hemorrhage
Adrenal insufficiency (especially with bilateral adrenalectomy or impaired function of the remaining gland)
Pneumonia
Deep vein thrombosis (DVT) and pulmonary embolism (PE)
Ileus
Urinary tract infection
Persistent hormonal abnormalities.
Prevention Strategies:
Thorough preoperative assessment and preparation (especially for pheochromocytoma)
Meticulous surgical technique with early vascular control
Adequate hemostasis
Use of specimen retrieval bags to prevent tumor spillage
Early mobilization and appropriate prophylaxis for DVT/PE
Judicious use of steroids for adrenal insufficiency.
Key Points
Exam Focus:
PRA is a retroperitoneoscopic approach
Key steps include early adrenal vein ligation
Essential for managing pheochromocytoma, aldosteronoma, and Cushing's adenoma
Advantages include reduced pain and faster recovery
Perioperative management of pheochromocytoma with alpha and beta blockers is crucial.
Clinical Pearls:
In PRA, the kidney is a crucial landmark
The adrenal vein is short and drains directly into the IVC (right) or renal vein (left)
ligate it early
Consider the position of the spleen on the left and liver on the right during dissection
Always send specimens for histopathology
Be prepared for the potential need for conversion to open surgery.
Common Mistakes:
Failure to adequately prepare patients with hormonally active tumors (especially pheochromocytoma)
Inadequate hemostasis
Injury to the renal vein or IVC
Not using a specimen bag for potentially malignant tumors
Overlooking the possibility of bilateral adrenal disease.