39.

2 Laparoscopic Adrenalectomy

Ahmad Assalia, M.D.

Michel Gagner, M.D., FACS, FRCSC

A. Indications
1. Laparoscopic adrenalectomy (LA) is currently considered the pre-
ferred alternative to open adrenalectomy for the vast majority of
patients with small and medium-sized benign functioning and non-
functioning adrenal lesions (Table 39.2.1). The available data indicate
that the largest experience has been with aldosteronomas followed by
Cushing syndrome, nonfunctioning adrenal masses (“incidentalo-
mas”), pheochromocytoma, and Cushing’s disease. Other nonprevalent
reported indications included myelolipoma, cysts, adrenal hemor-
rhage, androgen-secreting tumors, and ganglioneuromas.
2. Laparoscopic adrenalectomy has been successfully performed in
several other conditions, including the following: but further experi-
ence is still required before the procedure can be used routinely.
a. Neuroblastoma
b. Congenital adrenal hyperplasia (CAH) in children
c. Isolated adrenal metastases
d. Masses larger than 10 to 12 cm
3. Contraindications to laparoscopic adrenalectomy include the
following:
a. Large invasive adrenocortical carcinoma: although limited expe-
rience with noninvasive malignant tumors yielded encouraging
results, an initial laparoscopic approach is an acceptable option
only in experienced hands at selected specialized centers
b. Metastatic pheochromocytoma to periaortic nodes
c. Untreated/uncorrectable coagulopathy
d. Other contraindications for general anesthesia and laparoscopy

B. Operative Approaches
Several laparoscopic approaches to the adrenal glands are recognized:
1. Lateral transabdominal with the patient in the lateral decubitus posi-
tion
2. Anterior transabdominal with the patient in the supine position
3. Retroperitoneal endoscopic adrenalectomy (lateral or posterior)
 39.2. Laparoscopic Adrenalectomy 453

Table 39.2.1. Indications for laparoscopic adrenalectomy.

1. Functional adrenal cortical masses
Cushing syndrome caused by benign cortisol-producing adenoma
Cushing’s disease after failed pituitary surgery, or after failure to control or
to find an ectopic tumor producing adrenocortico tropic hormone
Aldosterone-producing adenoma (Conn’s syndrome)
Rare virilizing/feminizing secreting tumors.
2. Functional adrenal medullary masses
Benign adrenal pheochromocytoma
3. Nonfunctional adrenal masses
Benign-looking incidentalomas (nonfunctioning adenomas) confined to the
adrenal glands and meeting accepted criteria for adrenalectomy (size
>4 cm at presentation or growth in follow-up)
Benign symptomatic lesions
Rare entities such as cyst, myelolipoma, and hemorrhage

Although no clear objective advantages of one surgical approach over the

others have been conclusively shown, the lateral transabdominal approach is the
preferred technique practiced by most surgeons, followed by the retroperitoneal
approach. Table 39.2.2 shows the possible advantages and disadvantages of each
approach. The two most common approaches (lateral transabdominal and
retroperitoneal) will be described separately in Sections C and D.

C. Lateral Transabdominal Approach

The lateral transabdominal approach to the left adrenal gland will be
described first, followed by the approach to the right adrenal.
1. Patient position and room setup
a. Place the patient in the left lateral decubitus position with the
left side up (Fig. 39.2.1). Position a cushion under the right flank
and a protective roll under the right axilla. The left arm is
extended over a board and secured. The right arm is positioned
parallel to the left, suspended on a board, and secured. Flex the
table to maximize the distance between the costal margin and the
iliac crest, and secure the patient’s torso and legs to the table with
a 2-in. cloth tape.
b. The surgical prep should extend from the nipple to the anterior
superior iliac spine, and from the midline anteriorly to the spine
posteriorly.
c. The surgeon and the first assistant stand facing the patient’s
abdomen (i.e., on the right side of the patient).
d. Place two monitors near the head of the table.
 454

Table 39.2.2. Surgical approaches in laparoscopic adrenalectomy.

Approach Advantages Disadvantages
Lateral • Less dissection, retraction, and better exposure • Change of position in bilateral adrenalectomy
transabdominal • Appropriate for large tumors • Certain difficulty in cases of peritoneal adhesions
• Other intra-abdominal pathologies may be
diagnosed and treated
• The most practiced approach
A. Assalia and M. Gagner

Anterior • No need for changing position in bilateral
transabdominal adrenalectomy
• Appropriate for large tumors
• Other intra-abdominal pathologies may be
diagnosed and treated
Retroperitoneal • No need for changing position in bilateral
endoscopic adrenalectomy (with jack knife position)
• Potential advantage in previous upper
abdominal surgery; obese and pregnant patients
• More dissection needed and much difficult exposure
• Longer operative time?
• More blood loss?
• The least practiced approach
• Small operative field: appropriate only for small
tumors (<5–6 cm)
• Inability to diagnose and treat concurrent
intra-abdominal pathology
• Lack of anatomical landmarks familiar to the average
abdominal surgeon
 39.2. Laparoscopic Adrenalectomy 455

Figure 39.2.1. Patient position for laparoscopic transabdominal left adrenalec-

tomy. A. Room setup for laparoscopic adrenalectomy. B. Placing the patient in
the lateral decubitus position takes advantage of patient positioning to roll the
viscera out of the operative field.

2. Trocar placement and choice of laparoscope

a. Although closed technique with Veress needle is possible, we
prefer the open technique to access the abdomen and estab-
lish pneumoperitoneum. This is done at the left anterior axil-
lary line, approximately 2 cm below and parallel to the costal
margin. Insufflate to 15 mm Hg and place a 10-mm trocar at the
Veress insertion point.
b. Insert a 10-mm 30-degree laparoscope through this port.
c. Place the second 10-mm trocar under the eleventh rib at the
midaxillary line.
456 A. Assalia and M. Gagner

Figure 39.2.2. Placement of trocars in laparoscopic transabdominal left adrena-

lectomy. Three 10-mm trocars are usually placed initially; if a vascular stapler
is needed, the middle trocar can be changed to a 12-mm port.

d. Place the third 10-mm trocar more medial and anterior to the
first trocar. Position this trocar along the midclavicular line,
lateral to the rectus muscle.
e. A fourth trocar (5 mm) may be inserted dorsally at the cos-
tovertebral angle to retract the spleen. This port is usually not
necessary in patients with normal-size spleens.
f. The trocars should be at least 5 cm or, more optimally, 10 cm away
from each other.
g. Place the laparoscope through the anterior-most trocar with the
two middle trocars as the surgeon’s operating ports (Fig. 39.2.2).
3. Left adrenalectomy
a. Working with laparoscopic dissector and scissors, mobilize the
splenic flexure medially to expose the lienorenal ligament (see
Chapters 32, 33, and 37).
b. Incise the lienorenal ligament inferosuperiorly approximately 1
cm from the spleen. Stop the dissection when the short gastric
vessels are visualized posteriorly behind the stomach. This
maneuver allows the spleen to fall medially, exposing the
retroperitoneal space.
c. If necessary, retract the spleen gently with an atraumatic retrac-
tor passed though the most posterior (fourth) trocar.
d. Laparoscopic ultrasound may be used as an adjunct to identify
the adrenal gland, the mass within the gland, and the adrenal vein
(see Chapter 13).
 39.2. Laparoscopic Adrenalectomy 457

e. Grasping the perinephric fat, dissect the lateral and anterior part
of the adrenal gland. Hook electrocautery or ultrasonic scalpel
are useful instruments for this phase of the dissection.
f. Avoid grasping the adrenal gland or tumor directly, as the fragile
tissue is likely to tear. Sometimes it is possible to grasp the con-
nective tissue around the tumor or adrenal gland. At certain points
in the dissection, the shaft of an instrument may be used to gently
push the adrenal gland away from the region of interest, creating
a space in which to work. The shaft of an instrument may also be
used to elevate the adrenal gland.
g. Tilt the table to the reverse Trendelenburg position.
h. For smaller adrenals (<5 cm), dissect the adrenal gland infero-
medially. The adrenal vein may be identified early in the dissec-
tion, dissected using a right-angle instrument, and clipped with
medium to large titanium clips, using three clips proximally and
two clips distally. Continue the dissection superomedially, clip-
ping adrenal branches of the inferior phrenic vessels.
i. For larger glands (>5 cm), dissect the adrenal gland superiorly,
clipping the adrenal branches of the inferior phrenic vessels. Clip
and divide the adrenal vein last (Fig. 39.2.3).

Figure 39.2.3. Division of left adrenal vein.

458 A. Assalia and M. Gagner

j. Place the adrenal gland in an appropriately sized impermeable

nylon bag. Remove the bag through the original trocar site by
using a Kelly clamp to spread the abdominal wall musculature.
The abdominal incision may have to be enlarged to remove the
specimen (Chapter 8).
4. Right adrenalectomy
a. Patient position and room setup are the reverse of those
described for the left adrenal.
b. Trocar placement and choice of laparoscope
i. Access is gained using the open technique at the right ante-
rior axillary line, approximately 2 cm below and parallel to
the costal margin. Palpate the liver carefully to avoid the
edge of the liver. Place a 10-mm trocar for the 30-degree
angled laparoscope at this site.
ii. Place three additional 10-mm trocars 2 cm below and paral-
lel to the subcostal margin. Position one trocar in the right
flank, inferior and posterior to the tip of the eleventh rib, and
the other two more anterior and medial. The most medial
trocar should be lateral to the edge of the ipsilateral rectus
muscle.
iii. The trocars should be at least 5 cm or, more optimally,
10 cm away from each other (Fig. 39.2.4).
iv. The two most lateral trocars are the surgeon’s operating
ports.
v. The most anterior port is used to place the fan retractor to
retract the right lobe of the liver anteriorly.
c. Performing the adrenalectomy
i. The surgeon works with the laparoscopic dissector and scis-
sors passed through the two most lateral ports.
ii. Insert the fan retractor along the most anterior port and
retract the right hepatic lobe anteriorly.
iii. Lyse the right lateral hepatic attachments and the right tri-
angular ligament up to the diaphragm.
iv. Laparoscopic ultrasound may be of assistance in identify-
ing the anatomy.
v. Identify the inferolateral edge of the right adrenal gland and
dissect inferiorly.
vi. Tilt the table to the reverse Trendelenburg position.
vii. For adrenal glands less than 5 cm in diameter, the right
adrenal vein can be visualized early in the operation. Iden-
tify the right renal vein in the inferior most margin of the
dissection. Along the lateral edge of the vena cava, the right
adrenal vein is encountered and isolated using a right-angle
instrument. Secure the vein proximally with three titanium
clips and distally with two clips before transection. Clip and
divide the adrenal branches of the inferior phrenic vein as
the dissection proceeds superiorly (Fig. 39.2.5).
viii. For adrenal glands greater than 5 cm, perform the lateral
and superior dissection first, then dissect caudally along the
 39.2. Laparoscopic Adrenalectomy 459

Figure 39.2.4. Trocar placement for transabdominal right adrenalectomy. Four

10-mm working trocars are used; if a vascular stapler is needed, one of these can
be changed to a 12-mm port.

Figure 39.2.5. Division of right adrenal vein.

460 A. Assalia and M. Gagner

vena cava to identify the adrenal vein. Transect the vein as

previously described.
ix. A short fat right adrenal vein may require the vascular endo-
scopic stapler for secure division. Convert one of the 10-mm
trocars to a 12-mm trocar and carefully pass the stapler,
taking great care not to tear the vein.
x. Place the adrenal gland in an impermeable nylon bag and
removed via the original trocar.

D. Retroperitoneal Endoscopic Adrenalectomy:

Posterior Approach
The lateral and posterior approaches are very similar except for positioning
of the patient and the need for changing position in cases of bilateral
adrenalectomy with the lateral position. Herein, the posterior approach is
described.
1. Patient position and room setup
a. Place the patient in the prone jackknife position, with the arms
extended cephalad. Place support cushions longitudinally along
the patient’s torso and flex the table at the waist.
b. The surgical prep should extend from midscapula to the anterior
superior iliac spines.
c. The surgeon stands on the side of the pathology.
d. The first assistant stands opposite the surgeon.
e. Place two monitors cephalad on each side of the table.
2. Trocar placement and choice of laparoscope
a. Insert a balloon trocar into the retroperitoneal space 2.5 cm lateral
to the twelfth rib. Inflate the balloon by pumping it 25 to 30 times.
b. Pass a 10-mm, 30-degree laparoscope through the balloon trocar
and inspect the retroperitoneum.
c. Exchange the balloon trocar for a standard 10-mm trocar.
d. Place a second 10-mm trocar medially, just lateral to the ipsi-
lateral erectus spinae muscles.
e. Place a third 10-mm trocar laterally at the posterior axillary line.
The most lateral and most medial trocars are the surgeon’s oper-
ative ports (Fig. 39.2.6).
3. Performance of left adrenalectomy
a. Identify the kidney and the adrenal gland.
b. Dissect along the inferomedial border of the gland, exposing the
left renal vein.
c. Identify the adrenal vein, and clip and divide it.
d. Dissect and divide the remaining small vascular twigs.
e. Place the gland in an impermeable nylon bag and remove through
the original trocar site.
4. Performance of right adrenalectomy
a. Identify the kidney and adrenal gland.
 39.2. Laparoscopic Adrenalectomy 461

Figure 39.2.6. Placement of trocars in laparoscopic retroperitoneal adrenalec-

tomy. Three 10-mm trocars are usually used. Bilateral adrenalectomies can be
performed without repositioning the patient.
462 A. Assalia and M. Gagner

b. Dissect the adrenal gland attachments to the vena cava infero-

medially, clipping all vascular elements.
c. Complete the dissection and remove the gland as described
previously.

E. Complications
The available evidence suggests that laparoscopic adrenalectomy carries a
mean morbidity rate of about 10%. Table 39.2.3 shows the different reported
complications.
Bleeding is the most prevalent complication both intra- and postoperatively.
This is not surprising considering that both adrenals are highly vascularized and
situated in close proximity of major blood vessels. Together with organ injury,
these two complications occurring frequently in laparoscopic adrenalectomy are
discussed in this section.

Table 39.2.3. Complications of laparoscopic adrenalectomy.

Intraoperative
Bleeding due to vascular injury:
Adrenal vein
Renal vein
Inferior vena cava
Others
Organ injury
Liver
Kidney
Spleen
Pancreas
Bowel
Diaphragmatic injury
Others
Postoperative
Bleeding (intra-abdominal and abdominal wall)
Wound (short and long term)
Infectious
Cardiovascular
Pulmonary
Gastrointestinal
Urinary
Thromboembolic
Endocrine
Others
 39.2. Laparoscopic Adrenalectomy 463

1. Hemorrhage
a. Cause and prevention. Experience with open adrenal surgery
and intimate knowledge of anatomy are prerequisites for every
surgeon attempting laparoscopic adrenalectomy. Correct any pre-
operative coagulopathies. The dissection should be meticulous,
with special attention to hemostasis. Before clipping the adrenal
vein, trace it back to the adrenal gland to avoid damaging an
accessory renal vein. Securely clip the proximal portion of the
adrenal vein at least twice.
b. Recognition and management. Intraoperative hemorrhage is
easily identified and may require conversion to an open proce-
dure if hemostasis cannot be achieved. (See Chapter 6) Post-
operative hemorrhage is best detected by carefully monitoring the
patient’s vital signs and urine output overnight and physical diag-
nosis of the abdomen.
2. Organ injury
a. Cause and prevention. As with bleeding, the key for prevention
is familiarity with anatomy and delicate technique. Care should
be taken while dissecting along the superior aspect of a left
adrenal gland to prevent injury to the tail of the pancreas. Retract
liver and spleen gently to avoid injury and bleeding. High dis-
section in the abdomen may cause diaphragmatic injury, poten-
tially leading to tension pneumothorax.
b. Recognition and management. Damage to the liver or spleen
will present as intraoperative or postoperative bleeding. Damage
to the pancreas can present early as pancreatitis or later as pan-
creatic pseudocyst. These problems are usually self-limited but
may require medical or surgical management. In case of injury
to the diaphragm, closure with chest drainage will normally be
sufficient.
3. Others
Avoiding lengthy procedures will generally prevent severe hypercar-
bia and acidosis in cases of bilateral adrenalectomy. Appropriate
pharmacologic blockade is mandatory before surgery for pheochro-
mocytoma to avoid hypertensive crisis intraoperatively. Sufficient hor-
monal replacement is mandatory after bilateral adrenalectomy in
Cushing’s disease. Other complications are not specific to the proce-
dure and, therefore, are not discussed here.

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