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Laparoscopic adrenalectomy

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Laparoscopic adrenalectomy (LA) was first described in the literature in 1992, and has become the preferred method for the removal of benign functioning and non-functioning tumors of the adrenal gland <12 cm. The objectives of the present study are to review the experience of LA gained since it was first done in 1992 and to critically evaluate its effectiveness for the surgical management of endocrine hypertension; specifically pheochromocytoma, aldosteronoma and Cushing's syndrome and disease, as opposed to open adrenalectomy. The benefits of minimally invasive techniques for the removal of the adrenal gland include decreased requirements for analgesics, improved patient satisfaction, shorter hospital stay and recovery time when compared to open surgery. LA can be performed safely for bilateral disease and may become the standard of care for malignant tumors. Current limitations are operator-dependent and not a factor of limitations of minimally invasive techniques. A thorough pre-operative work-up is key for differentiating the various cases of hypertension and adequate pre-operative treatment is paramount when indicated.

Introduction

First described in the literature in 1992, laparoscopic adrenalectomy (LA) has become the preferred method for the removal of benign functioning and non-functioning tumors of the adrenal gland.1 Multiple retrospective comparative studies and case series have demonstrated the benefits of minimally invasive techniques in adrenalectomy, specifically the decreased requirements for analgesics, improved patient satisfaction, and shorter hospital stay and recovery time when compared to open surgery.2, 3, 4, 5, 6, 7, 8, 9 The objectives of this study are to review the experience of LA gained since it was first carried out in 1990, and to critically evaluate its effectiveness for the surgical management of endocrine hypertension; specifically pheochromocytoma, aldosteronoma, and Cushing's syndrome and disease, as opposed to open adrenalectomy (OA).1

Section snippets

Indications and contraindications

More than 75% of LAs are performed for endocrine causes of hypertension such as aldosteronoma, Cushing's syndrome and disease, and pheochromocytoma.9, 10, 11 Other indications for LA include adrenal cysts, metastases, myelolipoma, primary adrenocortical neoplasm, androgen-secreting tumors, adrenal hemorrhage, ganglioneuroma, and adrenal tuberculosis.9, 10 In the pediatric population, adrenal hyperplasia and neuroblastoma have also been reported.12, 13 LA is currently indicated for all benign

Operative technique

In a review of the largest published series, defined as at least 100 LAs, 19 papers were published (Table 2).3, 16, 18, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 In total, 2565 cases were reported. The majority of centers (70%) performed laparoscopic lateral transabdominal adrenalectomy (LTA), followed by posterior retroperitoneal endoscopic adrenalectomy (REA), in approximately 20%, and laparoscopic anterior trans-abdominal adrenalectomy (ATA).10 ATA usually requires increased

Morbidity and mortality

A total of 2565 cases were reported in large series of LA.3, 10, 16, 18, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 Operative times ranged from 65–240 mins (average = 137). The average blood loss was 81 ml and ranged from 20–106 ml. Length-of-stay averaged 3.3 days at high-volume centers, with a range of 1–5.8 days. The average complication rate was difficult to assess secondary to the lack of standardization of definition across all of the studies; nonetheless, the average rate appeared

Discussion

LA has become the procedure of choice for surgical treatment of endocrine hypertension. Multiple series in the literature have reported similar long-term results with LA and OA, but the minimally invasive approach has the added benefit of shorter convalescent times, improved cosmesis, and patient satisfaction.2, 3, 4, 5, 6, 7, 8, 9 LA for pheochromocytoma can be performed safely and with no increase and, perhaps, fewer, episodes of hemodynamic instability as compared to the open approach.10, 58

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