Laparoscopic adrenalectomy for large pheochromocytoma

A cadaveric anatomical study of the adrenals: vascular relationship

The adrenal gland is a retroperitoneal organ with intimate relationships with neighboring organs but also with the large retroperitoneal vessels. Our aim was to study the vascular relationships of the adrenal gland with the large abdominal vessels. Our work is an anatomical dissection of 80 fresh cadaveric adrenals. The subjects didn't have a history of retroperitoneal surgery. Dissection conditions were similar to those in the living. All measurements were made in situ. On the right side, the average distance between the adrenal gland and the renal vein (DR) was 13 mm (0-20). In one case, the adrenal gland laid directly on the right renal vein (DR = 0). The average length L, over which the right adrenal gland entered behind the inferior vena cava (IVC), was 8 mm (0-12). In 4 cases, the right adrenal was lateral to the IVC and in 6 cases the length L exceeded 10 mm. On the left side, the mean distance DL, separating the adrenal gland from the left renal vein was 8 mm with extremes ranging from 0 mm to 18 mm. In eleven cases, the adrenal gland laid directly on the left renal vein. The right adrenal gland has a close relationship with the IVC and is often located behind it. This close relationship helps to explain the increased incidence of IVC lesions during surgery. The left adrenal gland has an intimate relationship with the left renal vein and often lies on top of it. This explains the risk of injury to the left renal pedicle during left adrenal surgery.

Adrenal leiomyosarcoma in a young adult male

Leiomyosarcomas are known to typically originate from smooth muscle cell. Primary adrenal leiomyosarcoma is an extremely rare mesenchymal tumor associated with delayed diagnosis and poor prognosis. We report a rare case of leiomyosarcoma arising from the left adrenal gland in a 27-year-old male who presented with left side back ache. It was a solid mass of 9 × 6.5 × 7  cms situated superior to the left kidney. Left adrenalectomy was done and microscopic examination revealed a primary adrenal leiomyosarcoma.

Transperitoneal versus retroperitoneal laparoscopic adrenalectomy for large pheochromocytoma: Comparative outcomes

OBJECTIVES

To evaluate operative and oncological outcomes of laparoscopic adrenalectomy through a transperitoneal approach and retroperitoneal approach for large (>5 cm in diameter) pheochromocytomas.

METHODS

We retrospectively compared the results of a transperitoneal approach with those of a retroperitoneal approach in 22 patients (mean age 57.5 years, range 38-76 years) with unilateral large pheochromocytomas (12 right, 10 left). The mean body mass index, operation time, pneumoperitoneum time, estimated blood loss, fluctuation in blood pressure and complication rate were compared between the two approaches.

RESULTS

The mean tumor diameter (range) was 7.0 cm (range 5.2-15.5 cm), and no significant differences were observed between the transperitoneal approach and retroperitoneal approach in any baseline clinical parameter. For right-sided procedures, significant differences were found for operation time (113 vs 85 min), pneumoperitoneum time (93 vs 64 min) and estimated blood loss (96 vs 23 mL; P < 0.05, transperitoneal approach and retroperitoneal approach, respectively). No open conversion or recurrence was reported, but one right transperitoneal approach case required blood transfusion. No difference in these parameters was noted on the left side.

CONCLUSIONS

For right side procedures, the retroperitoneal approach is feasible, safer and faster than the transperitoneal approach for large pheochromocytomas. Early transection of the feeding artery is beneficial for managing the tumor and reducing the risk of bleeding.

Salvage Technique for Intraoperative Hemorrhage during Laparoscopic Resection of Large Pheochromocytoma: A Case Report and Literature Review

Aim

We described the use of a hand-port assisted laparoscopic adrenalectomy for excising a large 10 cm vascular left adrenal pheochromocytoma. The useful technical tips and important pitfalls to avoid for a successful outcome are discussed in this article.

Introduction

A 64-year-old man who was investigated for microalbuminuria was found to have a 10-cm left adrenal mass. Blood investigation and imaging confirmed it to be a pheochromocytoma.

Case report

Initial mobilization of the adrenal mass was performed laparoscopically using two 5-mm ports in the epigastric. While dissecting the inferomedial pedicle, the aberrant adrenal vessel was injured and resulted in torrential bleeding. A gelport for hand assistance was inserted as a salvage approach for hemostasis.

Conclusion

Hand-port assisted laparoscopic adrenalectomy is a very practical and easy-to-adopt technique that preserves the minimally invasive surgical advantages in patients with large adrenal masses.

Clinical significance: We advocate the use of hand-assisted laparoscopic adrenalectomy technique for complex pheochromocytoma as an alternative for surgeons with vast experience in laparoscopic adrenalectomy.

How to cite this article

Lee DJK, Tan YP, Singaporewalla RM. Salvage Technique for Intraoperative Hemorrhage during Laparoscopic Resection of Large Pheochromocytoma: A Case Report and Literature Review. World J Endoc Surg 2017;9(1):27-31.

[A clinical study of laparoscopic adrenalectomy for pheochromocytoma--analysis of clinical parameters influencing operative time and intraoperative systolic blood pressure]

PURPOSE

We retrospectively analyzed the preoperative clinical parameters which influence operative time and intraoperative maximum systolic blood pressure in patients undergoing laparoscopic adrenalectomy for pheochromocytoma.

MATERIALS AND METHODS

Between January 1992 and September 2010, we performed 28 laparoscopic adrenalectomies for pheochromocytoma at Hamamatsu University School of Medicine. These 28 cases were characterized based on the following parameters: body mass index (BMI), tumor size, history of hypertension, preoperative blood pressure, serum concentration of catecholamine, and 24-h urinary excretion of catecholamine metabolite. We retrospectively analyzed whether or not these parameters influenced operative time or intraoperative maximum systolic blood pressure.

RESULTS

All 28 cases of laparoscopic adrenalectomy were performed safely and without intraoperative complications and needed neither blood transfusion nor conversion to laparotomy. The median operative time was 203 minutes, and intraoperative hypertension (systolic blood pressure > 200 mmHg) occurred in 46% (13/28) of cases. Median day of discharge in all patients was post-operative day 5. Significant positive correlation was shown between tumor size and operative time and between intraoperative maximum systolic blood pressure and serum concentration of catecholamine or 24-h urinary excretion of catecholamine metabolite (p < 0.05).

CONCLUSION

The lengthened operative time for large tumors and elevated intraoperative blood pressure for tumors with high preoperative catecholamine activity necessitate careful perioperative management in patients receiving laparoscopic adrenalectomy for pheochromocytoma.

Adrenal cysts: Our laparoscopic experience

INTRODUCTION:

Cystic lesions of the adrenals are rare with an incidence of 0.06% in autopsies, and the most frequently found are either the endothelial cysts or the pseudocysts. We report our series of patients presenting with adrenal cysts.

MATERIALS AND METHODS:

The case records of patients presenting with adrenal cysts were reviewed and analyzed. Age, gender, presenting symptoms, physical examination findings, laboratory investigations and imaging records were all noted and analysed.

RESULTS:

During the 10-year study period, 14 patients, with a mean age of 41.36 ± 5.57 years, were diagnosed to have adrenal cysts. Laparoscopic excision of cysts was performed in three and laparoscopic adrenalectomy in the remaining eleven.

CONCLUSIONS:

Adrenal cysts are rare, and intervention is indicated whenever they are large (>5 cm), symptomatic, functional, and potentially malignant. Laparoscopic management of these cysts in the form of either decortication/excision is safe, effective, minimally invasive, with minimal blood loss and shorter duration of hospitalization.

Laparoscopic resection of large adrenal tumors

Results of this study suggest that laparoscopic adrenalectomy should be the treatment of choice for benign adrenal tumors. However, experience in advanced laparoscopic and open abdominal surgery is necessary in the management of large adrenal tumors.

Background:

Laparoscopic adrenalectomy has rapidly replaced open adrenalectomy as the procedure of choice for benign adrenal tumors. It still remains to be clarified whether the laparoscopic resection of large (≥8cm) or potentially malignant tumors is appropriate or not due to technical difficulties and concern about local recurrence. The aim of this study was to evaluate the short- and long-term outcome of 174 consecutive laparoscopic and open adrenalectomies performed in our surgical unit.

Methods:

Our data come from a retrospective analysis of 174 consecutive adrenalectomies performed on 166 patients from May 1997 to December 2008. Fifteen patients with tumors ≥8cm underwent laparoscopic adrenalectomy. Sixty-five patients were men and 101 were women, aged 16 years to 80 years. Nine patients underwent either synchronous or metachronous bilateral adrenalectomy. Tumor size ranged from 3.2cm to 27cm. The largest laparoscopically excised tumors were a ganglioneuroma with a mean diameter of 13cm and a myelolipoma of 14cm.

Results:

In 135 patients, a laparoscopic procedure was completed successfully, whereas in 14 patients the laparoscopic procedure was converted to open. Seventeen patients were treated with an open approach from the start. There were no conversions in the group of patients with tumors >8cm. Operative time for laparoscopic adrenalectomies ranged from 65 minutes to 240 minutes. In the large adrenal tumor group, operative time for laparoscopic resection ranged from 150 minutes to 240 minutes. The postoperative hospital stay for laparoscopic adrenalectomy ranged from 1 day to 2 days (mean, 1.5) and from 5 days to 20 days for patients undergoing the open or converted procedure. The mean postoperative stay was 2 days for the group with large tumors resected by laparoscopy.

Conclusion:

Laparoscopic resection of large (≥8cm) adrenal tumors is feasible and safe. Short- and long-term results did not differ in the 2 groups.

Intraoperative complications of laparoscopic adrenalectomy

A laparoscopic or retroperitoneoscopic access to the adrenal gland is the standard of care for adrenalectomy in most cases. Although in laparoscopic adrenalectomy the approach is minimally invasive, the procedure is challenging. This is reflected in the scope of possible complications. The surgeon must consider complications related to the anatomical topography of the adrenal gland, which typically encompasses the complications known from open surgery and complications related to the minimal invasive access. In this topic paper we will address the most frequently encountered complications of adrenalectomy: vascular injuries, injuries of the bowel, pleural tears, and injuries to the liver, spleen and pancreas. Fortunately, these complications occur rarely. However, many of these complications can have devastating consequences. Therefore, it's the surgeon's obligation to be aware of the possible complications he might encounter during laparoscopic adrenalectomy. This awareness is essential for their prevention and it helps the laparoscopic surgeon to identify complications intraoperatively.