The Role of Laparoscopic Surgery in Adrenal Disease
Samuel A. Wells, Jr.
American College of Surgeons
Chicago, Illinois 60611-3211
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Introduction
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THE PRACTICE of abdominal surgery
was dramatically changed in 1987 when the technique of laparoscopic
cholecystectomy was reported by Dubois and associates (1). The
procedure was rapidly and widely adapted in Europe, the Americas, and
Asia and quickly becoming the standard method of removing the diseased
gall bladder. Over the last decade minimally invasive operations have
been employed in the management of many surgical disorders,
particularly in the abdominal and thoracic cavities and the
retroperitoneum (2, 3, 4). With the initiation of each new laparoscopic
technique there have been predictable cycles characterized by an
"introductory phase," where the surgical technique is perfected
(virtually always associated with a learning curve), a "definition
phase" with exploration of technical variations and clarification of
the operative indications, and an "educational phase," where the
new technique is taught to house officers and surgical colleagues. This
phase sequence is somewhat flexible, and there is often much overlap
during the development, refinement, and maturation of a given
procedure.
Unfortunately, with the introduction of each new laparoscopic procedure
there have been no prospective randomized controlled trials comparing
the new technique to the standard "open" technique. Such
comparative analyses were precluded by the clear demonstration,
initially with laparoscopic cholecystectomy, that the "minimally
invasive procedures" had advantages such as shorter hospital lengths
of stay, less postoperative pain, and more rapid convalescence and
return to work. Furthermore, the patients, the hospitals, the
employers, and the health care providers found the minimally invasive
techniques preferable to the standard operative procedures. There are
no long-term reports of experience with any of the established
laparoscopic procedures.
In 1992 Gagner and associates (5) reported the first case of
laparoscopic adrenalectomy (LA) in a patient with Cushings syndrome
due to an adrenocortical adenoma. The technique proved highly
attractive to clinical endocrinologists, and within a short period of
time several medical centers reported their clinical series of patients
treated by this procedure (6, 7, 8). Currently, the technique has gained
wide acceptance among endocrine surgeons as the procedure of choice for
the resection of most adrenal tumors. However, there are some
controversial issues among the experts, as demonstrated in this Round
Table. We will review the most significant issues about LA and
focus especially on the controversies evidenced in the current
presentations.
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The technique of laparoscopic adrenalectomy:
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Even though there have been no prospective randomized trials
comparing LA to open adrenalectomy (OA), there have been retrospective
comparative evaluations. Thompson and associates (9) performed a
matched case-control study comparing 50 patients having open
adrenalectomy to 56 patients having adrenalectomy through a posterior
approach. They found that LA, compared to OA, was significantly
associated with shorter hospital stay, less postoperative narcotic use,
more rapid return to normal activity, increased patient satisfaction,
and less late morbidity. However, the laparoscopic procedure was
associated, with longer operating room time and higher cost. Similar
results have been reported by Prinz (10) and by Brunt et al
(11), who found that LA had distinct advantages compared to OA.
It has been noted by several authors that a posterior retroperitoneal
LA is preferable to an anterior LA, especially in patients who have
either bilateral adrenal tumors, prior to extensive abdominal
procedures with resultant adhesions and scar tissue formation, or
pre-existing cardiopulmonary disease (12, 13, 14). Posterior LA is not
indicated in patients with large adrenal tumors.
In laparoscopic adrenalectomy one sacrifices the tactile sense and must
manipulate the fragile adrenal gland with instruments in a
two-dimensional plane. This is a significant deficit for two reasons:
1) the adrenal gland is small and flat, and its true extent is often
difficult to define, even under direct observation; 2) the adrenal
gland is vascular and friable, and there is risk of damaging its
capsule and the parenchyma during instrumentation. This is a particular
problem in patients with Cushings disease, where adrenal cortical
cells spilt at surgery may increase to nodules under constant
endogenous ACTH stimulation.
In the present report of Lacroix (in this discussion), 3 of their 100
patients had incomplete resection of adrenal glands, as evidenced by
ACTH stimulation test in 2 patients and the recognition of a 1 mm
remnant of adrenal cortex left in situ in the third. Only 1
of these patients had a functioning tumor and is at risk for recurrent
disease.
Ushiyama and associates (15) reported a case of adrenocortical
carcinoma with recurrence 19 months after LA. At the original operation
for Cushings syndrome a 5-cm left adrenal cortical tumor was
resected. The histologically benign tumor was removed intact. The
patient developed recurrent symptoms and at reoperation had multiple
metastases both in the previous resection bed and at other
intraabdominal sites. It should be noted that there have been reports
of tumor recurrence at abdominal port sites in patients treated
laparoscopically for colon carcinoma or gall bladder carcinoma (16, 17). Also, one must also take great care not to damage the vasculature
to the kidney, especially on the left side where adrenal tumors often
overlie the renal hilus. The development of postoperative hypertension
is often the manifestation of an ischemic injury to the kidney
occurring at the time of adrenalectomy.
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The indications for laparoscopic adrenalectomy
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Laparascopic adrenalectomy was first performed in patients with
benign tumors of the adrenal cortex, but it soon was used to resect
pheochromocytomas. At present the procedure is used to resect a broad
range of benign adrenal tumors and even the adrenal glands in some
patients with nontumorous conditions, such as congenital adrenal
hyperplasia (see Merke and Cutler in this Controversy).
Lapara-scopic adrenalectomy is contraindicated for malignant
adrenal lesions because the tumors are often large, technically
difficult to remove, and vulnerable to breakage or incomplete
resection. Also the tumors may invade adjacent organs or regional lymph
nodes, which also require resection. It is of interest that Merke and
Cutler, in the present report, cite the use of LA in three infants with
neuroblastomas found during a mass screening program in Japan (18, 19).
Perhaps the generally good prognosis of neuroblastomas in this age
group precludes this rule, but it will be very interesting to learn of
the long-term evaluation of these patients. Size is the best indication
that an adrenal tumor is malignant, a matter that was controversial
among the Round Table participants. Lacroix and associates do not
consider size of major importance and report laparoscopic resection of
adrenal tumors as large as 10 or 13 cm. It is of interest that in their
series, Lacroix refers to two patients with nonfunctioning adrenal
tumors that met histological criteria for malignancy and two of four
patients with cortisol secreting adenomas, who were later shown to have
metastatic adrenal cortical carcinoma. There is no mention of the size
of these four lesions. It has been reported by Page and associates (19)
and Ross and associates (20) that tumors larger than 6 cm in diameter
or weighing more than 100 g are highly likely to be malignant.
Norton (in this Controversy) cites their work in recommending that such
large lesions should be resected by an open technique. There is no
reliable preoperative radiographic or biochemical test that indicates
the biological nature of an adrenal tumor; even on histological
examination it is very difficult, if not impossible, to tell if the
neoplasm is cancerous. Often this only becomes evident when tumor
spread is demonstrated beyond the confines of the adrenal capsule.
The matter of resecting incidentally found adrenal tumors is also
controversial. Lacroix and associates reported the removal of 15
nonfunctioning adrenal adenomas and 2 myelolipomas. Relatively clear
guidelines have been developed for the management of patients who
incidentally are found to have adrenal tumors (21, 22, 23). If these tumors
have no endocrine function, are less than 6 cm in size, and do not
enlarge with time, they can be left alone as virtually all such lesions
are benign and harmless. The availability of a technique for easily
removing these lesions is not necessarily an indication for doing
so.
Laparascopic adrenalectomy has clear applicability in the
management of patients with benign adrenal neoplasms. Even though LA
has distinct advantages compared with OA, much thought needs to be
given to the indications for the application of the technique. There is
still controversy in certain areas that will only be clarified as the
"definition phase" matures and there is long term evaluation of
large numbers of patients who have been treated by this technique.
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Footnotes
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Address all correspondence regarding these controversies and
requests for reprints to: Dr. Samuel A. Wells, Jr., American College of
Surgeons, 633 N. Saint Claire Street, Chicago, Illinois
60611-3211.
Received May 19, 1998.
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