Adrenalectomy

Published on 11/04/2015 by admin

Filed under Surgery

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 2181 times

CHAPTER 19 Adrenalectomy

INDICATIONS FOR ADRENALECTOMY

I. Aldosteronoma

A. Aldosteronomas are the most common functional adrenal tumor and the most common cause of primary hyperaldosteronism (see Table 19-1). Patients classically present with hypertension refractory to multiple medications and hypokalemia. Other symptoms include headaches, polyuria, nocturia, muscle weakness, and cramping.
B. The presence of a unilateral adrenal lesion with biochemical evidence of primary hyperaldosteronism (see Table 19-1) is an indication for adrenalectomy. When imaging shows either bilateral normal glands or bilateral adrenal nodules, adrenal vein sampling may be used to establish the laterality of the lesion. Patients with lateralizing venous sampling benefit from adrenalectomy. Laparoscopic adrenalectomy is the procedure of choice because these lesions are generally small and benign. In contrast, bilateral aldosterone hypersecretion is managed medically (typically with spironolactone).

III. Pheochromocytoma

C. The presence of an adrenal tumor with biochemical evidence of a pheochromocytoma (see Table 19-1) is an indication for adrenalectomy. Manipulation of a pheochromocytoma during surgery can result in the release of large amounts of catecholamines and hemodynamic instability. All patients should receive α- and β-antagonists and volume replacement before surgery. α-Blockade must be initiated before β-blockade because hypertensive crises can result from unopposed alpha stimulation.

COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY

See Figure 19-3.

There are multiple operative approaches to adrenalectomy. Traditionally, adrenal resections were performed in an open fashion through one of four approaches: transabdominal, lateral flank, posterior retroperitoneal, and thoracoabdominal. The laparoscopic approach has largely supplanted the lateral flank and posterior retroperitoneal approaches and is described in detail. The retroperitoneal laparoscopic and open approaches are briefly reviewed.

Port Placement

image

Figure 19-5 Port placement for laparoscopic adrenalectomy.

(From Cameron J: Current Surgical Therapy, 7th ed. Philadelphia, Mosby, 2001.)

Right Adrenalectomy

image

Figure 19-6 A, The right triangular ligament of the liver is divided to allow for medial rotation of the right lobe. B, The medial border of the adrenal is dissected to expose the inferior vena cava and right adrenal vein.

(From Brunt LM: Laparoscopic adrenalectomy. In Eubanks WS, Swanstrom LL, Soper NJ [eds]: Mastery of Endoscopic and Laparoscopic Surgery. Philadelphia, Lippincott Williams & Wilkins, 2000, p 325.)

Left Adrenalectomy

image

Figure 19-7 A, The splenocolic ligament is divided (dotted line), followed by division of the splenorenal ligament (dashed line). B, The spleen is rotated medially, and the kidney is retracted laterally. The adrenal vein is ligated at the inferomedial border of the adrenal with endoscopic clips.

(From Brunt LM: Laparoscopic adrenalectomy. In Eubanks WS, Swanstrom LL, Soper NJ [eds]: Mastery of Endoscopic and Laparoscopic Surgery. Philadelphia, Lippincott Williams & Wilkins, 2000, pp 326, 327.)

Other Operative Approaches

III. The open posterior retroperitoneal approach, performed through a hockey-stick incision on the back (Fig. 19-8), has been almost entirely supplanted by laparoscopic approaches. This approach allows for visualization of both adrenal glands, but provides limited working space. Furthermore, the incision is not well tolerated by patients.
image

Figure 19-8 Incision for open posterior approach to adrenalectomy (dashed line). The incision is extended inferiorly and laterally from the tenth rib to the posterior iliac crest.

(From Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice,17th ed. Philadelphia, Saunders, 2004.)

NORMAL POSTOPERATIVE COURSE

After an uncomplicated laparoscopic adrenalectomy, patients frequently feel well with limited analgesia, and can quickly tolerate a regular diet. If a patient is hemodynamically stable, the urinary catheter is removed on the morning of the first postoperative day. If a drain is left in place at the time of surgery, it is removed on the morning of the first postoperative day as well, assuming minimal, nonbloody drainage. Often, patients can be discharged from the hospital on the first or second postoperative day.

Patients who undergo open adrenalectomy generally have a more prolonged postoperative course. They often experience significant postoperative pain and require intravenous analgesia for several days after surgery.

Complications

Bleeding is the most common complication after laparoscopic adrenalectomy. Wound infections and intra-abdominal abscesses are relatively rare. As in all types of laparoscopic surgery, bowel injury can occur during port placement. Thermal injuries from the electrocautery device can occur at sites distant from the operative field. Other complications associated with adrenalectomy include: