Our Experience in Laparoscopic Adrenalectomy and Literature Review

Objective: To present our experience in laparoscopic adrenalectomy. Material and Methods: We have reviewed the records of our 64 adrenalectomy cases between August 2007 and October 2014 retrospectively. Of these cases, 63 had unilateral masses (25 right-sided, 38 left-sided) while only one patient had bilateral masses. The mean age of the patients was 46.72 years (26-81) and 44 (68.75%) patients were women and 20 (31.25%) were men. The average mass size was calculated as 35x29 mm and 48x34 mm in functional and non-functional adenomas, respectively. Results: Among the 64 patients, 48 were referred by endocrinology clinics while 16 patients were diagnosed incidentally. Fourteen patients had history of previous intra-abdominal surgery and five of them were continued as open surgery due to intraperitoneal adhesions. Mean duration of operation was 94±42 minutes and mean hospitalization time was 3.1±1,6 days. We did not encounter any major complications and recurrent or residual masses. Conclusion: Laparoscopic adrenalectomy is a safe method that can provide comfort to patients and surgeons in appropriate cases.


INTRODUCTION
Currently, it is easier to perform radiological and laboratory diagnostic methods to detect adrenal masses earlier and more frequent.In the last 20 years, the use of laparoscopy has become the first choice in surgical treatment of adrenal lesions.This method has the advantages such as lesser perioperative hemorrhage, lesser postoperative pain, shorter hospitalization time, earlier return to daylife and also offers a better vision for surgeons (1).
In our study, we aimed to present our experience in laparoscopic adrenalectomy applied for the surgical treatment of adrenal gland lesions.

MATERIALS AND METHODS
The records of 64 adrenalectomy cases performed between August 2007 and October 2014 were investigated retrospectively.Of these cases, 63 had unilateral adrenal masses (25 right-sided, 38 left-sided) while only one patient had bilateral masses.25 patients with unilateral right and left side in 63 cases, including 38 cases, and in 1 patient had bilateral adrenal masses.The mean age of the patients was 46.72 years (26-81) and 44 (68.75%) patients were women while 20 (31.25%) were men.All patients with functional adrenal mass were consultated with the Endocrine and Metabolic clinic to become ready for surgery.If necessary, appropriate steroid or alphablocker treatments were administered preoperatively.All cases were evaluated preoperatively via abdominal computed tomography or magnetic resonance imaging (Figure 1).All patients were given information about the disease before the operation.Following the appropriate surgical field cleaning under general anesthesia and in lateral decubitus position, we composed pneumoperitoneum via entering through midclavicular line with Veres needle.After creating 15-20 mm Hg pressure, 10 mm trocar was entered into the abdomen.Other 2 study ports were entered in the presence of the camera.Twelve patients required 4 th trocar usage.The fourth port was used for liver retraction.In left lateral transperitoneal approach, we entered into the retroperitoneum through the Toldt line.Descending colon was dissected for medialization.Splenorenal and splenocolic ligaments were cut.The abdominal wall and diaphragmatic connections of the spleen were separated.Then the upper pole of the left kidney was seen clearly and the main adrenal vein opening to enal vein was found.After dissected completely, it was clipped and ligated.If the adrenal gland was not fully set forth in obese patients, we were able to reach the renal vein by the help of gonadal vein; adrenal vein was found opposite to the location where the gonadal vein connected to the renal vein.
Right adrenalectomy is a different procedure due to liver retraction and therefore may require additional trocar usage.In right side adrenalectomy, after cutting the triangular ligament colon was medializated via entering through the Toldt line.The liver was carefully hold up.First, the main adrenal vein connected to vena cava inferior was clipped and ligated.Then, adrenal gland was dissected from the surrounding tissues and put in a laparoscopic specimen bag.
Due to the possibility of cathecolaminergic discharge, manipulation of the adrenal gland was paid attention.Material was taken out by enlarging of the trocar entry.Drains were placed through the no.5 trocars entry.All surgical procedures were performed by the same team.Patients' age, duration of surgery and hospitalization, complications, size of the masses and pathological diagnoses were recorded.

RESULTS
A total of 64 patients were included in our study.Fourty-eight of them were referred from endocrinology clinics (Conn's syndrome in 8 patients, Cushing's disease in 13 patients and the remaining were adrenal adenomas with resistant hypertension attacks).Sixteen were diagnosed incidentally.History of previous intra-abdominal surgery was present in 14 cases and five of these were continued as open surgery due to intraperitoneal adhesions.Patients' demographic data, operational information and the final pathology reports are summarized in Table 1.During the follow-up in endocrinology clinic due to acromegaly, hypertension and diabetes mellitus; bilateral adrenal adenoma (30x22 mm at right side, 44x30 mm at left side) was detected in one patient.Aldosteron levels in the left adrenal vein were found as >500 in this patient, then left adrenalectomy was performed and pathology report was adenoma.Postoperative follow-up of the patient is still ongoing by endocrinology clinics and metabolic condition is stable.Another case with 40x32 mm exophytic mass in left adrenal gland was performed organ-sparing adrenalectomy.The pathology of the patient who was discharged without any complications was reported as pheochromocytoma.
During postoperative follow-up, 4 patients had prolonged serous discharge for up to three days in the port entrance area and 2 patients required one unit of erytrocyte suspension transfusion.None of our patients were detected recurrent or residual masses.

DISCUSSION
Although laparoscopic adrenalectomy seems like the first option in the treatment of adrenal masses due to improving surgical techniques, instruments and experiences since 1992 (2), laparoscopic surgery is controversial in large masses with malignant potential and especially with periadrenal invasion and/or venous thrombosis.Although there is no consensus about the tumor size, there are some recent series about succesful laparoscopic surgery in adenomas with the size of ≥6 cm (3).
Transperiotenal and retroperitoneal methods may be performed in laparoscopic adrenalectomy.The lateral transperitoneal approach is preferred because of its wider study area and providing the opportunity to see and control the adjacent organs more clearly.Otherwise, retroperitoneal method has the low risk of intra-abdominal organ injury and postoperative intestinal complications, and it is preferable in cases with possible intraperitoneal adhesions due to previous surgery.In addition, retroperitoneal method may be preferred more often in morbidly obese cases because of the easier disection of thick periadrenal adipose tissue than lateral transperitoneal retroperitoneal method.GMJ 2016; 27: 37-39 Nalbant et al.

Laparoscopic adrenalectomy 38
However, narrow study area and lower chance of additional port input if necessary are the limiting factors of the use of retroperitoneal method (4).We prefer the lateral decubitus transperitoneal approach in our clinic.
Though it is a minimally invasive procedure, laparoscopic adrenalectomy has complications.Hemorrhage is the most common one and also the most common cause of the conversion to open surgery (5).The complication rates are expressed in the literature as 5-17% (6,7).In a study conducted by Assalia and Gagne, complication rate was found to be 9.5% in 2,550 cases of laparoscopic adrenalectomy.Of them, 40% were bleeding complications.Organ injury rate was 4.2% and rate of conversion to open surgery was 3.6%; the most common cause was bleeding (29.7%) (8).Detection of local and/or vascular invasion, size of the liver and adrenal adenoma, abdominal adhesions and diaphragm injury may be the other reasons for the convertion to open surgery during laparoscopic adrenalectomy (9).In our study, we had to continue as open surgery in 5 patients.The reasons were hemorrhage in postoprative period without need for transfusion in one patient and intraperitoneal adhesions in the others.On the other hand, we may also experience vascular injuries.The risk for vasculary damage is more frequent especially in right adrenalectomy during the dissection of vena cava inferior.In literature, the rate was shown as 0.7-5.4% (10)(11)(12)(13)(14). Bowel injuries are most frequently encountered in duodenum, while damage of the liver and spleen can occur more frequently during the dissection of the adrenal glands.The most important issue at this point is to keep to the anatomic rules during dissection.Primarily, demonstrating the adrenal vein at the connection region of renal vein and inferior vena cava is a facilitating factor to diminish the risk for complication.Permongkosol et al. (11) and Fahlenkamp et al. (14) reported the overall rate of pancreatic injuries as 0.2-0.4%.Nobuo et al. (15) reported atelectasis, angina, paralytic ileus, hematoma, wound infection and pulmonary embolism in the postoperative period.In our study, we did not experience any intra-abdominal organ injury in our patients.
More frequently, benign lesions are demonstrated in the pathological evaluation of adrenalectomy specimens.In the series of Parnaby and colleagues (16), pathological evaluation of 101 patients demonstrated benign lesions in 70, nonfunctional adrenal tumors in 5, adrenal carcinoma in 17, metastatic adrenal carcinoma in 3, contralateral adrenal metastasis in 3, retroperitoneal sarcomas in 2 and mixed type adenoma in 1 patients.Zakarias et al (17) reported similar pathological results in another laparoscopic adrenalectomy series of 52 patients.Of these, 34 were reported as benign lesions, while 18 were malignant adrenal masses.The pathological results of our study were similar to the literature.Malignant masses were followed correlated with oncology clinic

CONCLUSION
The experience gained from the cases which were suitable for laparoscopic treatment, we believe that laparoscopic adrenalectomy is an effective and reliable treatment method with the advantages of shorter hospitalization time, shorter return-time to daily activities, superior cosmetic results and lesser blood loss.

Figure 1 :
Figure 1: MR image of 61x55x52 mm solid lesion in the right adrenal gland.

Table 1 :
Features of our adrenalectomy cases