The Journal of Clinical Endocrinology & Metabolism Vol. 83, No. 9 3043-3046
Copyright © 1998 by The Endocrine Society
Five-Year Experience with Laparoscopic Adrenalectomy at Hôtel-Dieu in Montréal: Endocrinologist’s Perspective
André Lacroix
Centre Hospitalier de l’Université de Montréal (CHUM)
Montréal, Québec, Canada, H2W 1T8
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Introduction
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THE WIDESPREAD use of high quality
noninvasive adrenal imaging with ultrasound, computed tomography (CT),
and magnetic resonance imaging (MRI) has greatly increased the
detection of adrenal masses during the last 15 years. In addition,
developments in hormonal investigations, in nuclear medicine scanning
with 131I-6-iodomethyl-19- norcholesterol (NP-59) or
131I-metaiodobenzylguanidine (MIBG), and in fine needle
aspiration (FNA) biopsies have facilitated the diagnosis and etiology
of the adrenal masses (1). It has now become easier to identify the
preclinical (1, 2) or overt hormone secreting adrenal tumors as well as
the larger or progressing nonfunctional adrenal masses for which there
is an indication of surgical removal.
Surgery remains the basis of treatment, and major technical progress
has also occurred in this field. Already available for years in
gynecology, endoscopic surgery began enthusiastically with laparoscopic
cholecystectomy in 1987 and is now widely practiced in general surgery
and urology for the removal of several abdominal and pelvic organs. The
growth of minimally invasive surgical approaches was stimulated by the
advent of better instrumentation for dissection and hemostasis,
improved video imaging, and the potential reduction in pain, duration
of hospitalization, and cost of the procedures.
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Laparoscopic adrenalectomy at Hôtel-Dieu, 1992–1997
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Retroperitoneal exploration and laparoscopic nephrectomy were
first performed in 1991 (3). A year later, Michel Gagner at
Hôtel-Dieu hospital in Montréal successfully removed
adrenals through the laparoscopic lateral transperitoneal approach in
three patients (4). His first attempts for laparoscopic adrenalectomies
in humans were preceeded by extensive experience with advanced
laparoscopic abdominal surgery in humans and by experimental
laparoscopic adrenalectomy in a porcine animal model. Several
discussions between the endocrinology, anesthesiology, and surgery
teams and our presence during experimental laparoscopic adrenalectomy
in the porcine model preceeded the agreement to propose this approach
to our first patient. A 52-yr-old woman with Cushing’s syndrome
secondary to a left 3 cm adrenal adenoma developed an acute perforated
diverticulitis that required a colostomy performed by laparoscopy by
Dr. Gagner; the patient was treated with ketoconazole to control the
hypercortisolism during the following 3 months. She agreed to undergo
the first attempt at a laparoscopic adrenalectomy, which was
successfully performed at the same time as the closure of the
colostomy. Shortly thereafter, a bilateral adrenalectomy was performed
in a 38-yr-old male patient with Cushing’s disease that persisted
after two pituitary surgeries and radiotherapy. I was present in the
operating room during the entire procedure and was quite impressed not
only by the technical skills of the surgeon, but mainly by the fact
that the magnification of the anatomical structures through the
laparoscope appeared to facilitate the identification and dissection of
the various structures. Based on these two initial successful
approaches, the medical, surgical, and anesthesiology teams agreed to
use the same laparoscopic approach in a 60-yr-old male patient who
presented with a 3.5 cm right pheochromocytoma; following medical
preparation, the laparoscopic removal of the pheochromocytoma was
performed without any complications.
The transperitoneal lateral approach, developed and used in this
center, is described in detail elsewhere (5, 6). From April 1992 to
November 1996, a total of 100 adrenal explorations and resections were
performed in 88 patients by laparoscopy by a team led by Michel Gagner,
initially at Hôtel-Dieu hospital in Montreal until June 1995 (63
adrenalectomies), and then at the Cleveland Clinic Foundation (7, 8).
The current surgical team in our center (Drs. Alfons Pomp, Gail Breton,
and Daniel Pharand) have performed an additional 22 adrenalectomies
since June 1995, for a total experience of 85 adrenalectomies in 74
patients at Hôtel-Dieu. The indications for the adrenalectomies
included 25 (number of adrenals) pheochromocytomas, 17 adrenal
Cushing’s syndrome, 15 nonfunctioning adenomas, 13 aldosteronomas, 6
Cushing’s disease, 3 macronodular adrenal hyperplasia, 2 ectopic ACTH
syndrome, 2 metastasis, and 2 myelolipomas. Bilateral adrenalectomies
were performed in 6 patients with bilateral pheochromocytomas, in 3
patients with persistent Cushing’s disease, in 1 patient with an
ACTH-producing pancreatic carcinoid tumor, and 1 patient with bilateral
macronodular adrenal hyperplasia and vasopressin-dependent Cushing’s
syndrome (9); another patient with ectopic adrenal ß-adrenergic
receptors, Cushing’s syndrome, and bilateral macronodular adrenal
hyperplasia underwent only a left adrenalectomy (203 gm), as his
hypercortisolism was controlled by propranolol (10). Two of the
nonfunctional tumors met pathology criteria of adrenal carcinoma
without relapse to date; another was a medullary cyst, while one was a
retroperitoneal sarcoma mimicking an adrenal mass, and others were
corticoadrenal adenomas. In 4 cases of cortisol-producing adenomas, the
patients presented with a preclinical syndrome (2), while the other
cases had overt Cushing’s syndrome; 2 of these cases eventually proved
to be adrenocortical carcinomas as they developed metastasis. In 2
cases operated for isolated lung cancer metastasis, dissection was
difficult because of perirenal fat invasion. For the first 68
adrenalectomies, the overall mean operation time (anesthesia and
surgery) was 2.1 h, with the right side requiring more time, an
average of 138 min, compared with 102 min for the left side (7); this
difference in operation time became negligible in recent cases (8). The
time for bilateral adrenalectomies averaged 318 min. The mean diameter
of the lesions removed was 4.1 cm (1–14 cm). Overall, the early mean
postoperative stay was 3 days, with a range of 2–19 days (7). The mean
number of postoperative narcotic injections was 5.5. Postoperative
complications included 3 anemias not requiring transfusions, 2 wound
hematomas, 2 exacerbations of renovascular hypertension without any
evidence of renal vascular damage during the surgery, 2 urinary tract
infections, 1 deep vein phlebitis with pulmonary embolus, 1 pulmonary
edema, 1 subdural hematoma after a fall secondary to postural
hypotension after removal of a pheochromocytoma, 1 cholecystitis, 1
colonic pseudo-obstruction, and 1 wound infection.
Complete resection was performed in all but three patients. In the
first patient undergoing bilateral adrenalectomy for refractory
Cushing’s disease, a small portion of the inferior left adrenal was
not resected; this was not detectable by repeat CT or iodocholesterol
scans, but low levels of cortisol were slightly increased by ACTH
stimulation (20–50 nmol/L), and this has not progressed during 5 yr of
follow-up. One patient who had previously undergone a left radical
nephrectomy, including left adrenalectomy for renal cell carcinoma,
underwent a right laparoscopic adrenalectomy following the appearance
of a 4 cm adrenal lesion that was diagnosed as a nonsecreting cortical
adenoma; resection of the right gland was later shown to be incomplete
by a short ACTH stimulation test and by the limited requirement of only
10 mg of hydrocortisone in the morning and no mineralocorticoid
replacement. There was no evidence of functional left adrenal on
iodocholesterol scan, and there has been no evidence of progression of
the residual portion of the right adrenal on CT scan. In one patient
operated for a right medial nonfunctional adenoma, a small 1 mm rim of
partially intrahepatic normal adrenal was left in place and has not
progressed since. Conversion to open surgery was necessary in three
patients including an early patient who had a 15-cm angiomyelolipoma
where vessels could not be clipped securely. In another patient
believed to have a nonfunctional left adenoma, a retroperitoneal
sarcoma originating from the posterior retroperitoneal muscles was
identified at laparoscopy, which was converted to open surgery to
perform an en bloc resection. During the removal of a right
3.5 x 3.7 nonfunctional adenoma, an adrenal vein bleeding
necessitated conversion to open surgery. Re-operations during the same
admission were required in two patients and were performed by
laparoscopy. One patient with asymptomatic gallstones developed acute
cholecystitis 4 days post-adrenalectomy and underwent a
cholecystectomy. A patient receiving anticoagulation for a mitral valve
prosthesis required a laparoscopic evacuation of a retroperitoneal
hematoma.
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Pheochromocytomas
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We performed 25 laparoscopic adrenalectomies on 19 patients with
pheochromocytomas. Pheochromocytomas were unilateral in 13 patients and
bilateral in 6 others. There were 5 multiple eudocrine neoplasia (MEN)
2 A patients and 2 MEN 2 B patients, 5 of whom underwent bilateral
surgery; one patient with Von-Hippel-Lindau syndrome had a unilateral
right pheochromocytoma removed. In the two MEN 2 B patients,
unsuspected pheochromocytoma metastases were identified and removed at
surgery; in both cases, a single small (<2 mm) superficial liver
capsule metastasis was present, and in one case, a 3 cm large
metastatic node between the aorta and vena cava was resected; there is
no evidence of recurrence of metastatic pheochromocytoma after 3 and 4
yr of follow-up. Seventeen patients received alpha-blocker preparation
(mostly prazocin) and volume expansion in the preoperative period. The
average tumor size was larger in pheochromocytomas (6.3 cm) compared
with other tumors (3.5 cm). Operating time was longer in
pheochromocytomas, on average 3.8 h in unilateral adrenalectomy,
and 6.3 h in bilateral cases. Elevated blood pressure, with
systolic over 200 mmHg or diastolic over 100 mmHg occurred in 11
patients and was well-controlled with various iv antihypertensive
agents. Hypotension (systolic BP <80 mmHg) occurred after venous
clamping in 3 bilateral and 7 unilateral cases and was corrected easily
with volume expansion. Major complications included a megacolon
requiring endoscopic decompression in a woman with MEN 2 B, alimentary
tract ganglioneuromatosis, and a history of Ogilvy syndrome. Patients
left the hospital on average 8.4 days after the operation. In the
patients with uncomplicated courses, the average postoperative stay was
5.7 days. Of the four patients who remained hypertensive in follow-up,
two required only monotherapy to control hypertension. One other
patient with diffuse atherosclerotic disease, developed hypertension 8
months after right adrenalectomy, secondary to a left renal artery
stenosis. In another patient with MEN 2 A and bilateral silent
pheochromocytomas, severe hypertension occurred 2–3 weeks after
bilateral laparoscopic adrenalectomy; investigation revealed anomalies
in both renal arteries, with a stenosis in a polar renal branch on one
side with a renal segmental perfusion deficit and an aneurysm of
another renal arterial branch on the opposite side compatible with
fibrous dysplasia. There was no evidence of inadvertently placed
surgical clips on the renal arteries; the hypertension was easily
controlled with ß-blockers.
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Should every patient requiring adrenalectomy be referred to a
laparoscopic surgeon?
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Since the initial reports (4, 11), several other authors worldwide
have published case reports of their experiences with a small series of
patients using different laparoscopic approaches to treat various
adrenal pathologies (partial review in ref. 7). The results of
laparoscopic adrenalectomy should be compared with those of open
surgery; there are no large prospective randomized trials that have
been published to date comparing both approaches. Historical
comparisons with standard open procedures (12, 13, 14, 15, 16) have indicated
longer operative time for laparoscopic vs. open surgery,
similar operative complication rates, earlier mobilization and oral
feeding, shorter duration of hospitalization, and decreased requirement
of pain medication in the laparoscopic approach. This has also been our
experience; the patients indicate a high degree of satisfaction, and we
have not seen patients with long-term postoperative pain, which was
frequent in the previously used open posterior approach that included
rib removal. In the hands of experienced surgeons, the procedure can be
performed in an acceptable amount of time and can be used for a range
of disorders affecting the adrenal glands; the morbidity remains as
significant as open surgery. The need to convert to open procedure has
been low to date.
In initial editorials and reactions to adrenal laparoscopic surgery,
caution concerning the use of this approach in pheochromocytomas and in
larger lesions was expressed (17). In general, the size of the lesion
is not a limitation in our experience; our surgeons successfully
removed adrenals as large as 13 cms x 6 cms x 3.5 cms,
weighing 203 g in a case of macronodular adrenal hyperplasia (10)
or 99 g in a 10 cm pheochromocytoma. The concern with size is more
a debate regarding neoplastic potential than technical feasibility of
laparoscopic surgery. Only surgeons with great experience should
approach pheochromocytomas and lesions larger than 6–8 cm by
laparoscopy; larger lesions should be approached by laparoscopy only if
known to be benign, as in macronodular hyperplasia with Cushing’s
syndrome. Laparoscopic adrenalectomy can be used for patients with
bilateral diseases including pheochromocytomas. A major advantage of
the transperitoneal adrenalectomy by laparoscopy is that the abdominal
cavity and the liver, in particular, can be explored with the aid of
magnification via the laparoscope. In our pheochromocytoma patients, we
discovered two small metastatic lesions to the liver that had not shown
up in the radiological and isotopic preoperative evaluation, and we
also performed a liver biopsy for a suspect lesion. Through the
retroperitoneal approach, open or laparoscopic, these lesions would not
have been accessible.
Now that the minimally invasive procedure of laparoscopic adrenalectomy
is becoming more available and the techniques and surgical times are
improving with experience, it has been suggested that management of
nonfunctional adrenal masses could be reconsidered. Most primary
malignant tumors are over 6 cms in diameter (1), and the general
consensus previously was to recommend removal of all adrenal lesions of
this size or greater. For lesions between 3 to 6 cms, there is,
however, no clear consensus, and several authors were reluctant to
recommend surgery because of the morbidity involved. With laparoscopic
adrenalectomy, lesions that are relatively small but suspect,
i.e. growing on follow-up CT scans or suspect in MRI (high
signal intensity) or iodocholesterol scans (low uptake), could be
removed and definite diagnosis obtained earlier, leading to cure for
primary cancers and rapid diagnosis with possible impact on management
in metastatic lesions. In our view, taking into account that morbidity
rates remain similar for both surgical approaches, we have not modified
our indications for surgery, which include all functional lesions and
nonfunctional lesions larger than 3 cms and growing or suspect lesions
in patients without other major comorbidity. Clearly malignant lesions
should be removed by open surgery. This raises a controversy in that it
is not possible to fully distinguish, before surgery, and even before
long-term follow-up, whether certain lesions are benign or malignant;
however, in the presence of elevated DHEAS or estradiol levels, of a
very heterogenous high-density radiological lesion, we would now favor
open surgery. In lesions not clearly malignant, a laparoscopic
exploration is performed and converted to an open surgery if there is
local evidence of malignancy.
The absolute contraindications for laparoscopic adrenalectomy include
primary or metastatic invasive adrenal malignancies because
extensive en bloc surgery and node dissection will be
necessary. Patients with malignant pheochromocytoma, as suggested by
MIBG or MRI scans, would be better approached by open surgery. A
coagulopathy that could not be controlled before surgery would also
constitute a contraindication. Previous surgery or trauma in the area
may create dense adhesions that will make dissection more difficult.
Diaphragmatic hernias on the left side will elevate the splenic flexure
of the colon and make dissection more difficult. An adrenal mass larger
than 10 cm will have many blood vessels connecting to the
retroperitoneal space, will require long dissections, and should not be
approached by laparoscopic route unless the surgeon has extensive
experience with the procedure.
Finally, the most important factor in the surgical management of
adrenal lesions is the experience of the surgical and anesthesiology
teams involved. There is a delicate balance for the surgeon between the
desire to perform glamorous new techniques and providing the best
possible care for the patient. The endocrinologist can be faced with
the human dilemma of an inexperienced surgeon who wishes to introduce
the use of this surgical technique in their center. There are now
numerous opportunities for qualified and well-trained laparoscopic
surgeons to attend high quality advanced courses in specific surgical
techniques, such as laparoscopic adrenalectomy including the use of
animal models. The first interventions should be conducted in the
presence of an experienced colleague. Hospitals where the number of
these procedures are limited on a yearly basis should not perform
laparoscopic adrenalectomies. The qualified surgeon should not hesitate
to convert to open surgery if there is any such indication during the
procedure. As laparoscopic techniques become more widely known and
applied, as in other areas of medicine, the indications for the
conventional open approaches will gradually decrease and the
laparoscopic management of adrenal masses will become the standard of
treatment for benign adrenal lesions.
The author wishes to thank the Hôtel-Dieu adrenal surgical
team, including Dr. Michel Gagner for his pioneering contribution to
this field, and Drs. Alfons Pomp, Gail Breton, and Daniel Pharand for
their continued enthusiastic collaboration. The contributions of Dr.
John S. Weisnagel in reviewing our initial patient’s data and of all
the other members of the Endocrinology and Nephrology Divisions in
patient’s evaluation and care are also greatly appreciated.
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References
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Introduction
Laparoscopic adrenalectomy at...
