Laparoscopic Adrenalectomy : Lessons Learned From 100 Consecutive Procedures

To compare the relative merits of conventional transabdominal and posterior methods with a laparoscopic approach for adrenalectomy. A retrospective cohort study of consecutive series of patients having unilateral adrenalectomy for lesions less than 10 cm in diameter. University hospital. Ten patients who underwent laparoscopic adrenalectomy: 11, transabdominal adrenalectomy; and 13, posterior adrenalectomy. Operative time, estimated blood loss, length of hospital stay, and postoperative parenteral analgesic need. There was no significant difference in the operative time for laparoscopic and anterior adrenalectomy (mean +/- SD, 212 +/- 77 minutes vs 174 +/- 41 minutes), but the time for posterior adrenalectomy was significantly shorter (139 +/- 36 minutes) (P < .01). The mean (+/- SD) hospital stay after laparoscopic removal (2.1 +/- 0.9 days) was significantly shorter than the stay after anterior (6.4 +/- 1.5 days) and posterior (5.5 +/- 2.9 days) adrenalectomy. The postoperative need for parenteral pain medication as measured by the number of doses and the total milligrams of meperidine hydrochloride administered was significantly less with laparoscopic adrenalectomy compared with either open procedure (P < .0001). Laparoscopic adrenalectomy may take longer to perform than conventional open approaches but it has clear-cut advantages in shortening postoperative hospital stay and lessening postoperative analgesic requirements. It may be the preferred method for most patients requiring adrenalectomy.

In our retrospective study we compare the effectiveness and safety of transperitoneal laparoscopic versus open adrenalectomy in 40 patients with benign hyperfunctioning unilateral adrenal tumors. Patients 1 to 20 underwent open adrenalectomy between July 1988 and July 1992, and patients 21 to 40 underwent the laparoscopic procedure between September 1992 and January 1994. Student's t test for unpaired data was used to compare intraoperative and postoperative results, and morbidity observed in the 2 groups. The affected adrenal gland was successfully removed in all cases. Mean operative time was significantly longer for laparoscopy, although it shortened progressively due to the learning curve effect. Blood loss was significantly less with laparoscopy, while only 3 patients undergoing open surgery required blood transfusions. Overall invasiveness and analgesic requirement were significantly lower with laparoscopy. The intervals to oral intake and ambulation, hospital stay and return to preoperative normal activity were shorter with laparoscopy. Major complications were noted only in open surgery patients. At 3 months all patients in both groups were cured of the underlying adrenal disease. We conclude that transperitoneal laparoscopic adrenalectomy is equally effective and less invasive than open surgery, and that it should be considered the first choice therapy for benign hyperfunctioning adrenal tumors.

In the traditional kidney position three trocars are inserted after creation of a pneumoperitoneum: 10 mm periumbilical (port I), 10/12 mm subcostal (port II) and 12/10 mm above the iliac spine (port III) in the mamillary line. After laterocolic incision the colon is dissected away from the lateral wall. Thereafter two 5-mm trocars (ports IV, V) are inserted into the lateral abdominal wall parallel to parts II and III. Following clipping and dissection of the ovarian (spermatic) vein, the ureter is isolated and incised. Then the cranial part of the ureter is used as a retractor exposing the renal hilum for dissection of the renal vessels. The main renal artery and vein are dissected separately by use of an endoscopic stapling device (Endo-GIA, white magazine). Finally, the kidney including Gerota's fascia is isolated from the adrenal and the upper peritoneum. Entrapment of the organ is performed with a specially designed bag (Lap-sac). The neck of the bag is brought out onto the surface of the abdomen (via port II/III) allowing digital morcellation with index finger inside the bag and removal of the organ in several pieces. We have applied this technique for 17 procedures in the upper retroperitoneum: 9 transperitoneal laparoscopic nephrectomies (TLN) for benign disease (5 hydronephrosis, 3 renovascular disease, 1 chronic pyelonephritis), 3 radical TLN including adrenalectomy for renal cell carcinoma (T2G2), 1 adrenalectomy for a cortical adrenaloma, 1 nephroureterectomy, 1 diagnostic ureterolysis and 2 modified retroperitoneal lymphadenectomies for stage I testicular cancer. The mean operation time was 4 h (2-5), the mean postoperative hospital stay 6 days (4-12).(ABSTRACT TRUNCATED AT 250 WORDS)