- One 5mm, three 12mm disposable trocars
- One 5mm fenestrated grasping forceps
- 5mm Harmonic scalpel
- Fan retractor
- Retrieval bag
- Two 5mm needle holders
For selected patients, laparoscopic adrenalectomy is a safe alternative to open surgery. Indications include - functional adrenal masses eg Cushing's Adenoma, aldosterone-secreting adenoma (Conn's disease) and adrenal cortical hyperplasia (Cushing's disease). It is very good for nonfunctional adrenal masses or "incidentalomas". The laparoscopic dissection of Cushing's adenoma can prove difficult due to the large volumes of retroperitoneal fat.
Bilateral adrenalectomies for Cushing's disease have been described. Laparoscopic removal of pheochromocytoma has proven a safe alternative in skilled hands. Contraindications include adrenal carcinoma, masses >10 cm.
Bristol Laparoscopic Associates have used two approaches to the adrenal gland.
- Transabdominal approach - left adrenal
Position the patient (right lateral decubitus & table flexed). Place a 12mm laparoscope port 2cm below and parallel to the costal margin in the left anterior axillary line. Place a second 12mm trocar under the 11th rib in the mid axillary line. Place a third in the mid clavicular line. If the spleen is in the way position a fourth trocar at the costovertebral angle to reflect it. As a general rule, space the trocars about 10cm from one another. The middle ports are the operating ports.
Mobolise the splenic flexure medially to allow for exposure and incision of the lienorenal ligament to demonstrate the short gastric vessels. This allows the spleen to fall medially, exposing the retroperitoneal space. The adrenal gland, mass and vein are identified.
Grasping the perinephric fat, dissect the lateral and anterior parts of the adrenal gland. Make sure to avoid grasping the adrenal gland or tumor directly, as the tissue may tear. Tilt the table to a reverse trendelenburg position.
For smaller adrenals (<5cm), the gland is dissected inferiomedially. This allows earlier identification and division of the adrenal vein. As dissection continues upwards, branches of the inferior phrenic vessels are clipped. For larger glands, dissection proceeds superiorly, clipping the adrenal branches of the inferior phrenic vessels. Clip and divide the adrenal vein last.
Place the tumour in an impermeable nylon bag and withdrawn through the umbilical port.
Operate through the two most lateral ports with a fenestrated dissector and scissors. A fan retractor placed through the most anterior port allows the right hepatic lobe to be retracted anteriorly. Divide the right hepatic attachments and the right triangular ligament. The adrenal mass is then identified. Laparoscopic ultrasound may help in defining the anatomy. The inferiolateral edge of the right adrenal gland is identified and dissected inferiorly.
For "small" glands less than 5cm, the inferior adrenal vein is visualized early and ligated/divided. The adrenal branches of the inferior phrenic vein are then clipped and divided as the dissection is completed cranialy. For adrenals greater than 5cm, we would suggest that the lateral and superior dissection are completed first before carrying the dissection caudally towards the adrenal vein, which is then clipped and divided.
The patient is placed in prone jackknife and a balloon trocar is placed in the retroperitoneal space and insufflated (then removed). Operating and retracting ports are then inserted under vision.
Left Adrenalectomy The kidney and the adrenal gland are again identified. The inferiomedial border of the gland is identified and dissected, exposing the left renal vein. The vein is divided along with remaining vascular twigs. The gland is then removed in an Espiner bag through the original trocar site.
Hemorrhage - Intraoperative hemorrhage is easily identified and controlled using standard techniques. If bleeding cannot be controlled convert to an open procedure. Familiarity with intraabdominal and retroperitoneal anatomy is an absolute must. Before clipping the adrenal vein, trace it back to the adrenal gland to avoid damaging an accessory renal vein. Take care along the superior aspect of a left adrenal dissection to avoid injury to the tail of the pancreas. Retract liver and spleen to avoid injury and bleeding.