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Laparoscopic versus Open Adrenalectomy

University of California San Francisco and San Francisco Veterans Affairs Medical Center San Francisco, California 94121-1598

	Introduction

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LAPAROSCOPIC surgery has dramatically reduced the morbidity of many abdominal surgical procedures resulting in less pain, shorter hospitalization, and more rapid return to work (1). An important guiding principle of laparoscopic surgery is to perform the same procedure laparoscopically as through open techniques. Incisional pain and discomfort are reduced by laparoscopy, because the operation is performed through multiple small incisions (1–2 cm) in the skin, muscle, and fascia rather than a solitary long incision (15–20 cm). Pain is not caused by dissection and mobilization of internal viscera, which is similar in both open and laparoscopic procedures, but rather by the magnitude of the abdominal wall incision. Larger incisions result in more pain that lengthens recovery time. Reduction in pain and rapid recovery has spurred patients and referring physicians to select minimally invasive techniques for common surgical procedures like cholecystectomy, splenectomy, and repair of hiatal hernias (2, 3, 4). Despite the fact that there is less pain associated with laparoscopic surgery (1, 2, 3, 4), there have not been other clearly identified benefits. In fact, some studies indicate that laparoscopy results in an increased frequency of complications. For example, studies suggest that laparoscopic cholecystectomy has a higher incidence of bile duct injury than open cholecystectomy (2, 5). Prospective controlled studies assessing critical outcome parameters are essential before any procedure can be unequivocally recommended. Unfortunately, for most laparoscopic surgical procedures, these data are not available. This report will analyze the role of laparoscopic adrenalectomy in the management of patients with adrenal diseases.

There are no prospective randomized trials with sufficient numbers of patients and meaningful follow-up data to convincingly compare open to laparoscopic methods of adrenalectomy. However, there are numerous recent retrospective studies comparing the two procedures (6, 7, 8, 9, 10). In general, these studies have been performed by advocates of the laparoscopic approach who compare recent laparoscopic methods to previous open techniques. These comparisons are limited scientifically, because the design is retrospective and nonrandomized. Nevertheless, each study suggests that laparoscopic adrenalectomy is associated with less pain, better functional status, and earlier return to full activity (6, 7, 8, 9, 10). These differences are consistent, meaningful, and readily apparent to anyone who has examined patients after these procedures. However, postoperative pain and recovery are not the only meaningful variables following surgery. Few studies have examined the results of adrenalectomy in these patients. Are the biochemical results similar following laparoscopic adrenalectomy? Are long term results similar? These questions are presently unanswered. It is possible that laparoscopic adrenalectomy is associated with a higher incidence of local recurrence of tumor, because of incomplete resection or spilled cells. Additional long-term follow-up studies will be necessary to address these issues. Before unequivocally recommending one approach, it will be critical to know that not only is pain less, but outcome is similar.

Laparoscopic adrenalectomy is a new approach to an old procedure. The surgeon performing it is responsible for understanding the indications. This is mentioned because some authors suggest that a nonfunctioning adenoma is an indication for laparoscopic adrenalectomy (11, 12). This is not the case because excellent data from long-term follow-up studies and autopies demonstrate that these tumors are clinically insignificant and do not warrant adrenalectomy (13). This leads to the notion that adrenal surgery requires more knowledge than simply how to do the procedure. It involves understanding the indications for the procedure and the postoperative management. Correct decision making is important in adrenal surgery. Interpretation of radiographs and data analysis may be critical in planning an operation. Further, prescribing the correct dose and duration of glucocorticoid replacement therapy following resection of an adenoma requires special knowledge (14). Adrenal surgery is best performed by a surgeon who is experienced and knowledgeable in both endocrine and laparoscopic surgery, and not simply laparoscopic methods.

Large size of an adrenal tumor is a contraindication for laparoscopic adrenalectomy. Laparoscopic adrenalectomy should not be performed in patients suspected of having malignant neoplasms of the adrenal. For cortical tumors and pheochromocytomas, size of the tumor correlates with malignant potential. Weight greater than 100 g or size equal to 6 cm is highly suggestive of malignancy (13, 15). Laparoscopy is a limited approach to the adrenal, requiring manipulation of the gland to remove it. In patients with cancer, wide resection of the gland with contiguous structures provides the best chance for cure. Further, in patients with gall bladder and colon cancer, there has been an unusually high probability of port site recurrences following laparoscopic surgery (1). Therefore, in patients with adrenal tumors approximately 6 cm in size who have a significant likelihood of cancer, open adrenalectomy is recommended to avoid manipulation of the tumor and to maximize the chances of complete resection (9).

Type of adrenal tumor is not a contraindication for laparoscopic adrenalectomy. Previously, some have suggested that a pheochromocytoma should not be removed laparoscopically. Recent reports indicate that this is not the case, and even pheochromocytomas as large as 5 cm have been successfully removed by laparoscopic methods (16, 17). Proper preoperative preparation with phenoxybenzamine or alpha-methyltyrosine has been effective at minimizing intraoperative hypertensive episodes during insufflation with carbon dioxide, surgical manipulation, and resection. Laparoscopic adrenalectomy for pheochromocytoma in the setting of multiple endocrine neoplasia (MEN 2A and 2B) is the method of choice (Norton, JA; unpublished data). Patients generally have benign, small tumors within the adrenal.

Recent technical advances make laparoscopic adrenalectomy safe and able to be performed by more surgeons. The lateral transperitoneal approach is preferred over the retroperitoneal approach because of improved working space and gland visualization (16). Operative identification of the adrenal gland is facilitated by the use of laparoscopic ultrasound (9, 17). The gland is identified as a hypoechoic mass, and relationships with other structures (inferior vena cava, the renal vein, and the adrenal vein) are clarified. The harmonic scalpel simplifies dissection and effectively controls bleeding from the small arteries that perfuse the gland along its medial borders. The adrenal vein is separately ligated with hemoclips to provide secure hemostasis. The resected gland is removed from the port site in an occlusive bag to decrease peritoneal implantation and port site recurrence. In fact, our analysis suggests that operative time and blood loss are not increased by laparoscopic methods (9).

In summary, despite the unavailability of prospective randomized trials, laparoscopic adrenalectomy has become the method-of-choice to perform most adrenalectomy procedures, as it greatly reduces postoperative pain and shortens recovery. The surgeon should be aware of the indications for adrenalectomy. Laparoscopy has not changed the indications. Pheochromocytomas are not a contraindication to laparoscopic adrenalectomy, but malignant tumors are best removed by an open procedure. Procedural advances like lateral transabdominal approach, laparoscopic ultrasound, harmonic scalpel, clips and bags have shortened the operative time and reduced blood loss. Thus, for small (<6 cm) functioning adrenal tumors and hyperplasia that require adrenalectomy, laparoscopic adrenalectomy appears to be the procedure of choice. Careful long-term follow-up of these patients is recommended to exclude recurrence from incomplete resection, ectopic tissue, or tumor spillage.

Accepted May 19, 1998.

	References

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