Transperitoneal Laparoscopic Adrenalectomy: Outline of the Preoperative Management, Surgical Approach, and Outcome

Abstract

The laparoscopic approach to the adrenal gland has evolved to be the gold standard for most cases of adrenal conditions requiring surgical treatment. There is general consent about the safety, efficacy, and reproducibility of laparoscopic adrenal surgery. Compared to the open surgery, significant advantages with regard to shorter hospitalization time, decreased postoperative morbidity, improved cosmetics, and quicker convalescence are evident. The anatomic location of the adrenal gland led to the development of various approaches, including lateral transperitoneal, anterior transperitoneal, lateral retroperitoneal, posterior retroperitoneal, and even transthoracic approaches. The lateral transperitoneal approach is the technique most frequently used for laparoscopic adrenalectomy. A large operative field provides good orientation and visualization of familiar landmarks known from open surgery. In particular in the early learning curve this represents an advantage of the transperitoneal laparoscopic approach. This article describes in detail the indications, contraindications, preoperative evaluation, surgical technique, management of intraoperative complications, and outcome after lateral transperitoneal adrenalectomy.

Introduction

Minimally invasive techniques have profoundly changed the surgical approach to the adrenal gland. The clear discrepancy between the relatively small size of the target organ and the extent of the incision necessary to provide its adequate exposure and avoid resection may not be found in any other urologic ablative procedure than in adrenal surgery. Due to the establishment of laparoscopic approaches that circumvent this drawback while incorporating all advantages of the open approach, laparoscopic adrenalectomy has become the generally accepted standard of care for surgical management for the vast majority of cases in little over a decade [1], [2], [3], [4], [5]. It is safe to state that today adrenal surgery is the success story of laparoscopy in the realm of urology [6].

Since Gagner’s initial report on the laparoscopic approach for adrenalectomy in 1992, several authors have reported the feasibility and efficacy of the laparoscopic technique for the treatment of different adrenal diseases. The advantages of laparoscopic over open adrenalectomy are well documented and include a shorter hospital stay, a decrease in postoperative pain, shorter interval between surgery and return to preoperative activity level, and improved cosmetics [7].

The anatomic location of the adrenal gland in the upper retroperitoneal space, cranial and medial of the kidneys and in close proximity to the diaphragm, led to the development of various approaches, including lateral transperitoneal, anterior transperitoneal, lateral retroperitoneal, posterior retroperitoneal, and transthoracic approaches [8], [9], [10]. The lateral transperitoneal approach is the technique most often used for laparoscopic adrenalectomy [11]. Our results with laparoscopic lateral transperitoneal adrenalectomy for benign and malignant conditions of the adrenal gland are presented.