Adrenalectomy by retroperitoneal laparoendoscopic single site surgery.

BACKGROUND: Laparoscopic adrenalectomy is the current standard for treatment of benign adrenal disease. To reduce the invasiveness of surgery, new techniques have been recently proposed, such as mini-laparoscopy, natural orifice transluminal endoscopic surgery, and laparoendoscopic single site surgery (LESS). Herein, we describe one case of adrenalectomy by retroperitoneal LESS using conventional laparoscopic instruments and ports. CASE REPORT: A 52-year-old female patient with an incidental finding of a 3-cm mass in the left adrenal was referred to us. Preoperative blood concentrations of catecholamines, aldosterone, and cortisol, and urinary excretion of vanilmandelic acid were normal. She underwent an adrenalectomy by retroperitoneal LESS using conventional instruments and ports. Operative time and estimated blood loss were 82 minutes and ≤50cc, respectively. She was discharged 12 hours after surgery. No intra- or postoperative complications occurred. Pathological analysis of the specimen identified an adrenal cortical adenoma.
CONCLUSION: Adrenalectomy by retroperitoneal LESS using conventional laparoscopic instruments is feasible. Further studies must be performed to evaluate safety, indications and benefits of this approach.

INTRODUCTION

Since the initial description of laparoscopic adrenalectomy in 1992,[1] the management of adrenal disease has evolved dramatically. Nowadays, laparoscopic adrenalectomy is considered the standard of care for benign adrenal lesions,[2-5] resulting in less postoperative pain and morbidity, as well as improved cosmetic results with respect to its open counterpart.[5-7]

The laparoscopic operation can be performed via 3 different approaches: the lateral transperitoneal, the lateral retroperitoneal, or the posterior approach,[8] using 3 to 5 ports.[2,9,10] The safety and efficacy of these techniques have already been documented, and each respective approach offers a unique set of advantages and disadvantages.[3,4,11,12]

Recent developments regarding laparoscopy have been directed toward further reducing morbidity and improving the cosmetic outcome. These include the use of mini-laparoscopic 2-mm needle-ports,[13,14] use of natural orifices,[15-18] and more recently, use of transumbilical access (or laparoendoscopic single site surgery, LESS) by laparoscopy[19] or retroperitoneoscopy.[20]

In this article, we describe one case of adrenalectomy by retroperitoneal LESS using conventional laparoscopic instruments and ports.

CASE REPORT

A 52-year-old female patient required medical assistance due to left lower quadrant abdominal pain. She underwent a CT scan that showed acute diverticulitis and a 3-cm lesion in the left adrenal. After clinical management of the diverticulitis, she was referred to us for the treatment of the adrenal mass. She had a previous history of moderate hypertension requiring 2 antihypertensive agents. A preoperative workup included blood concentrations of catecholamines, aldosterone, and cortisol, and urinary excretion of vanilmandelic acid, which were all normal.

She was advised to undergo an adrenalectomy by retroperitoneal LESS. Informed consent was obtained before the surgery.

A modified 5-mm trocar was used to try to reduce external clashing of the instruments and to improve range of motion (.

(A) Modified trocar for LESS (arrow). (B) Skin incision. (C) Position of the trocars. (D) Surgical specimen.

While the patient was under general anesthesia, she was positioned in a right lateral decubitus. The axilla was protected with a small pillow, and the arm was maintained on an armrest in a functional position.

The skin was incised longitudinally for 2cm, 4cm below the 12th left costal arch in the left posterior axillary line (. After blunt dissection of the subcutaneous tissue, the left lumbar muscle and its fascia were identified and retracted. The retroperitoneum was reached, and the initial dissection was performed digitally. A 10-mm trocar was placed, and the retroperitoneal space was achieved using CO2 gas and the 30-degree endoscope. Two additional 5-mm adjacent trocars were placed (. In this way, the surgeon worked using 2 ports with the instruments in parallel.

The first landmark identified was the left psoas muscle. In a medial direction, the left genitofemoral nerve was identified above the psoas tendon.

Dissection was performed to identify the left kidney and its renal vein (. This vein was dissected up to the exposition of the adrenal vein (, which was clipped and divided. The adrenal artery was also identified and clipped (. Electrocautery was used to free the superior, lateral, posterior, and medial attachments of the adrenal gland (. After releasing the gland, it was put in a bag and held by a grasper. The trocars were removed, and all 3 adjacent skin incisions were united. The opening in the lumbar muscle was enlarged, and the bag was retrieved (.

(A) Renal artery (arrow) and vein (crossing posterior to the artery). (B) Adrenal vein dissected. (C) Placement of 5mm clips in the adrenal artery. (D) Dissection of the adrenal from the kidney.

The procedure was performed successfully in 82 minutes. Estimated blood loss was <50cc. Each intraoperative step could be accomplished with confidence, similar to standard multi-port laparoscopy. No intraoperative complications occurred.

The patient received clear liquids 6 hours after the procedure and was discharged from the hospital 12 hours after surgery. No complications were observed on follow-up postoperative consultations on days 7 and 30. Pathology analysis of the specimen identified an adrenal cortical adenoma.

DISCUSSION

Both the transabdominal and the retroperitoneal laparoscopic approaches represent a significant benefit in terms of patient recovery as opposed to open surgery, and in the past decade, laparoscopic adrenalectomy has become the procedure of choice for removing benign adrenal processes. Laparoscopy provides a magnified view of the operative field, allowing the precise identification of small vessels, and a more precise dissection with less blood loss compared with open surgery.[10] Compared with open procedures, laparoscopic adrenalectomy has been shown to be associated with reduced narcotic requirements, better cosmesis, shorter hospital stay and convalescence.[5-7]

The transperitoneal approach is more familiar to the general surgeon. It provides complete exposure of the superior retroperitoneum and allows for examination/therapy of the remainder of the peritoneal cavity. Even larger adrenal masses (>6cm) are amenable to transperitoneal dissection and resection. However, the transperitoneal approach increases the risk of injury to abdominal viscera, and bilateral transperitoneal adrenalectomies cannot be accomplished without repositioning the patient.[8]

The retroperitoneal approach is more familiar to the urologic surgeon.[8] In this surgical approach, (1) abdominal viscera do not compromise the exposition of the structures,[21,22] (2) there is no need for colon mobilization to reach the retroperitoneal space, reducing operative time, (3) no inconvenient adhesions develop when performed in patients who underwent multiple previous abdominal surgeries, and (4) there is a reduced incidence of postoperative ileus and intraperitoneal organ lesions, because there is no violation of the peritoneal cavity.[23] Disadvantages include a restricted working space, poor definition of anatomic structures, allowing loss of anatomic landmarks, and limitation of the movements.[22] Theoretically, the small area for retroperitoneal dissection limits the size of glands amenable to this technique.[8]

Laparoscopic posterior adrenalectomy offers a more direct access to the adrenal gland, minimizing the need for intraabdominal dissection. The first structure identified in this procedure is, in fact, the adrenal gland. It offers the advantage of the dissection without the interference of the intraabdominal organs. This approach also facilitates dissection in the individual with previous intraabdominal surgery by avoiding adhesions. Furthermore, there is no need to reposition the patient for bilateral tumors. The disadvantage of laparoscopic posterior adrenalectomy seems to be the limited space that determines the size of the tumor removed.[10]

Although laparoscopic surgery is considered a minimally invasive procedure, retrieval of laparoscopically resected specimens often requires enlargement of one of the ports or an additional incision. At the end of the procedure, patients generally have 3 to 5 incisions, each from 1cm to 4cm in length. Potential incision-related morbidity comprises (1) poorer cosmetic results, (2) injury to cutaneous nerves and chronic pain, (3) subcutaneous bleeding, and (4) incisional hernia development.[24]

Recently some authors have been using alternative techniques to diminish the above-mentioned incision-related morbidity, such as specimen morcellation,[10] transvaginal extraction,[25] natural orifice transluminal endoscopic surgery (NOTES),[15-18] and transumbilical surgery [also called E-NOTES (embryonic natural orifice transumbilical endoscopic surgery),[26] transumbilical endoscopic surgery (TUES), natural orifices transumbilical surgery (NOTUS), single-port, single-access, single-incision, keyhole surgery, or laparoendoscopic single site surgery (LESS), all based on the principle of a single abdominal incision to insert articulating laparoscopic instruments].[19,24,26,27] The feasibility of the afore-mentioned technique to perform an adrenalectomy was demonstrated by our group[19] using conventional instruments and ports.

To associate the advantages of the minimally invasive surgery with single access to those of the retroperitoneoscopic approach, the retroperitoneal LESS was proposed to our patient with an adrenal incidentaloma. Classic indications for surgery are features suggestive of malignancy, hormone hypersecretion, and lesions >6cm.[28] Surgical treatment of patients with nonhypersecretory adrenal incidentalomas <4cm in diameter is controversial, and these patients can be followed up clinically and by serial radiological scanning at regular intervals. We were able to perform the procedure using conventional instruments and 3 adjacently placed trocars. No major obstacles or difficulties were seen during the surgery. Because all the ports were placed adjacently, they were easily united in a single 4-cm incision to retrieve the specimen.

Disadvantages of the LESS technique include (1) the parallel and close lie of the right- and left-hand instrument shafts tends to result in “crowding” of the laparoscope and instruments,[26,29,30] (2) the clashing of instruments and the laparoscope is common and, as such, significant coordination between the surgeon and the camera person is essential,[30,31] (3) dissection through a single port is more difficult than in conventional multi-port laparoscopy, because of the lack of instrument triangulation.[29,30]

CONCLUSION

In this article, we confirmed the feasibility of adrenalectomy by retroperitoneal LESS using conventional laparoscopic instruments. It can be considered a potential alternative for traditional laparoscopic surgery, but further comparative studies and larger series on retroperitoneal and transperitoneal LESS are essential to evaluate the safety, indications, and benefits of each of these techniques and the potential advantages over the currently established conventional laparoscopy.