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Open or Laparoscopic Adrenalectomy: Surgical Technique and Complications

Indications for Adrenalectomy

Adrenalectomy is indicated for adrenal tumors larger than 6 cm or or with hormonal activity. Adrenal tumors <4 cm in size without hormonal activity require watchful waiting (with imaging controls). Adrenal tumors with 4–6 cm diameter without hormonal activity may be surgically removed or, depending on age and comorbidities, are managed by watchful waiting (with imaging controls).

Contraindications to Adrenalectomy

• Adrenalectomy should not be done without determination of hormonal activity. The identification of a pheochromocytoma is crucial since this tumor must be treated with alpha-blockers before surgery to prevent a hypertensive crisis.
• Coagulation disorders
• Other contraindications depend on comorbidities (surgical risk) and the importance of adrenalectomy on the patient's quality of life or life expectancy.

Surgical Technique of Adrenalectomy

Preoperative Patient Preparation:

• Perioperative antibiotic prophylaxis if risk factors for surgical site infections are present.
• Insertion of a transurethral catheter
• Epidural anesthesia, if an open-surgical approach is chosen

Surgical Approach:

Small adrenal tumors (up to 6 cm) may be treated with a flank incision, a laparoscopic (robotic-assisted), or a retroperitoneoscopic approach. A transperitoneal approach (midline laparotomy or subcostal incision) is preferable for larger adrenal tumors or adrenal pheochromocytoma (Brunt, 2006). Huge adrenal masses may need a thoracoabdominal incision

Flank incision:

Open adrenalectomy is usually done via a flank incision. The dissection is done between the 11th and 12th rib to spare the subcostal nerve. Blunt dissection of the layer between the renal fascia and the psoas muscle is done. The peritoneum is dissected off the ventral portion of the renal fascia until the renal vein is identified. On the right side, the duodenum has to be dissected off the vena cava (Kocher maneuver).

Retroperitoneoscopic access to the adrenal gland:

The retroperitoneoscopic access to the kidney and adrenal glands is described in the section retroperitoneoscopic nephrectomy. See also fig. retroperitoneoscopic access.

Laparoscopic access to the adrenal gland:

The laparoscopic access to the kidney and adrenal glands is described in the section laparoscopic nephrectomy.

Open transperitoneal approach:

The open transperitoneal approach to the kidney and adrenal glands is described in the section open radical nephrectomy.

Mobilization of the upper renal pole:

The upper pole of the kidney is dissected from the perinephric fat until the hilar vessels of the kidney are identified.

Left adrenalectomy:

First, dissect and divide the left suprarenal vein between clips near the renal vein. Now it is possible to dissect the adrenal gland circularly, while small vessels are clipped or coagulated.

Right adrenalectomy:

First, dissect the adrenal gland from the diaphragm and the upper pole of the kidney. Now the plane between the adrenal gland and vena cava is followed. The suprarenal vein is clipped or divided between sutures as the last step.

Lymphadenectomy:

If malignancy is suspected, retroperitoneal lymph node dissection between the diaphragm and renal hilus, including interaortocaval lymph nodes, is done.

Drains after adrenalectomy:

Draining of the retroperitoneal cavity is often performed but is probably unnecessary after uncomplicated adrenalectomy.

Care after Adrenalectomy

General measures:

Early mobilization. Respiratory therapy. Thrombosis prophylaxis. Laboratory controls. Wound inspections.

Analgesia after Adrenalectomy:

Analgesics with a combination of NSAIDs and opioids. Peridural anesthesia facilitates postoperative pain management after a flank incision or open transperitoneal approach.

Drains and Catheters:

• Wound drainage 0–2 days
• Bladder catheter 0–1 day

Hormone replacement therapy:

There is a risk of an Addisonian crisis (adrenal insufficiency) after unilateral adrenalectomy for Morbus Cushing since the contralateral adrenal gland is suppressed. After bilateral adrenalectomy, adrenal insufficiency must be prevented by hormonal substitution, please see section adrenal insufficiency.

Complications of Adrenalectomy

• Bleeding
• Infection
• Injury of the liver or spleen (splenectomy)
• Paralytic ileus, bowel injury, peritonitis
• Pancreatic injury, pancreatic fistula
• Pneumothorax
• Subcostal nerve injury and consecutive flank bulge
• Addisonian crisis (adrenal insufficiency)

References

Brunt, L. M. Minimal access adrenal surgery.
Surg Endosc, 2006, 20, 351-361.

  Deutsche Version: Adrenalektomie