Laparoscopic Adrenalectomy for Large Adrenal Tumors: Is the “vein First” Approach Really Worthwhile?

Giancarlo Basili, MD, Nicola Romano, MD, Federico Filidei, MD, Graziano Biondi, MD. Health Unit 5 Pisa, Pontedera General Hospital, General Surgery Unit.

The role of minimally invasive surgery for large adrenal tumours remains a highly controversial problem. Risks of inadequate margin resection and tumour spillage with the related possibilities of locoregional and port-site recurrence are documented by several studies and represent the major limitations of this procedure. Many studies have demonstrated that in case of suspected large adrenal masses, laparoscopic adrenalectomy could have outcomes similar to open procedures, when surgeon strictly adhering to standard oncologic principles.

The paramount surgical rule is to avoid capsular effraction, which dramatically increase the risk of locoregional recurrence from cellular seeding, even for benign tumours.

In our video we represent a case of a 75 year-old female patient affected by a large adrenal tumour (75 mm at its largest diameter), suspected for adrenocortical carcinoma, with no evidence of infiltration of periadrenal tissues or locoregional lymphadenopathy. A sharp and gentle dissection of the mass from the periadrenal tissues was obtained. Beginning inferiorly to the gland, a complete mobilization was achieved. The adrenal vein control was performed at the end of the procedure, avoiding any capsular effraction, in relationship to a large and almost complete mobilization of the gland.

Our experiences with large adrenal tumours confirm that if there is no evidence of the local invasion, minimally-invasive adrenalectomy can be safely achieved, provided that the oncologic surgical principles are observed.

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