Laparoscopic adrenalectomy: Gaining experience by graded approach

Abstract

Introduction:Laparoscopic adrenalectomy (LA) has become a gold standard in management of most of the adrenal disorders. Though report on the first laparoscopic adrenalectomy dates back to 1992, there is no series of LA reported from India. Starting Feb 2001, a graded approach to LA was undertaken in our center. Till March 2006, a total of 34 laparoscopic adrenalectomies were performed with success.Materials and Methods:The endocrinology department primarily evaluated all patients. Patients were divided into Group A - unilateral LA and Group B - bilateral LA (BLA). The indications in Group A were pheochromocytoma (n=7), Conn's syndrome (n=3), Cushing's adenoma (n=2), incidentaloma (n=2); and in Group B, Cushing's disease (CD) following failed trans-sphenoid pituitary surgery (n = 8); ectopic ACTH- producing Cushing's syndrome (n=1) and congenital adrenal hyperplasia (CAH) (n=1). The lateral transabdominal route was used.Results:The age group varied from 12–54 years, with mean age of 28.21 years. Average duration of surgery in Group A was 166.43 min (40–270 min) and 190 min (150–310 min) in Group B. Average blood loss was 136.93 cc (20–400 cc) in Group A and 92.5 cc (40–260 cc) in Group B. There was one conversion in each group. Mean duration of surgical stay was 1.8 days (1–3 days) in Group A and 2.6 days (2–4 days) in Group B. All the patients in both groups were cured of their illness. Three patients in Group B developed Nelson's syndrome. The mean follow up was of 24.16 months (4–61 months).Conclusion:LA though technically demanding, is feasible and safe. Graded approach to LA is the key to success.

Has experience changed the scenario in laparoscopic adrenalectomy?

“…In this series of 60 patients, we did not encounter any major complication. Minor complications were observed in three of 60 adrenalectomies performed in 49 patients (5%) that were comparable to reported studies [2,3,24]. Two patients in Group A developed wound infection that was treated with antibiotics while one patient in Group B developed incisional hernia.…”

“…Goitein et al [2] have suggested a minimum of 30 cases to master the technique of LA. A graded approach to achieve expertise also has been suggested [3]. The present study reviewed data of 60 adrenalectomies comparing the change of pattern in indications, size of tumor, duration of surgery, blood loss, morbidity and mortality after fi rst 30 cases.…”

Laparoscopic adrenalectomy for large tumours: Single team experience

“…The technique is described in detail elsewhere. [10] All patients were operated under general anaesthesia. Carboperitoneum was maintained at 12 mm Hg.…”

“…Herein we report our experience with 46 laparoscopic adrenalectomies performed for large adrenal masses (> 5 cm) and summarise the operative and postoperative outcomes. [10]…”

Nelson’s Syndrome

“…Radiographic evidence of corticotroph tumor growth is the most frequently used criterion for NS diagnosis, either alone 4,[13][14][15][16] , or in combination with increased ACTH levels and/or pigmentation 2,[17][18][19][20][21][22][23][24][25][26][27][28][29] . In the MRI era, early detection of marginal tumor growth (even before clinical manifestations become evident) is possible, giving ground to the concept of replacing the term NS with "corticotroph tumor progression" 14 .…”