We present our series of 46 Laparoscopic adrenalectomies (LA) for large adrenal tumors (> 5 cm) performed from July 2003 till September 2009. The department of endocrinology primarily evaluated these patients. Contrast-enhanced computerized tomography (CECT scan) or magnetic resonance imaging (MRI) were relied upon in all cases to look for the size of the gland, relation to IVC on right side, renal vein on left side and presence or absence of lymph nodes. Tumors with invasion of adjacent organs were excluded. Transperitoneal approach was used. Ports were standard but modified in some cases due to large size of the tumor. No hand-port or hand-assist was used. Difficulties encountered were overhanging nature of tumor, close proximity to renal vessels, desmoplastic reaction in pheochromocytoma and intact specimen retrieval. Literature seems markedly silent on retrieval of larger tumors. Joining of two ports and/or their extension was sufficient for intact extraction. 42 patients underwent LA (n = 46) for large adrenal tumors (bilateral – 4 patients). Mean age of the patients was 33.38 (14-62) years. The diagnosis confirmed on histopathology was pheochromocytoma (n=26), paraganglioma (n=4), adenomyolipoma (n=7), Cushing’s disease (n=4), schwannoma (n=1), tuberculosis (n=1), carcinoma (n=2) and adrenocortical sarcoma (n=1). The mean size of these tumors was 7.03cm (5-15 cm). 16 patients had tumor size more than 8 cm. The mean operative time was 116 min (45-270 min) and mean blood loss was 112.39 cc (20-400 cc). Conversion rate 10.87% (n = 5). Bleeding was the cause of conversion in three patients of large pheochromocytomas (size 8 cm), of which two patients were pregnant, technical difficulty in one patient of paraganglioma in the aorta caval window and local invasion in the patient of sarcoma. The mean in-hospital stay was 4 days (2-8 days) with no major complications. One patient (adrenocortical sarcoma) died of metastasis 3 months after surgery. The mean follow up is 26 months. The series shows that mere size should not be considered as a contraindication to laparoscopic approach in large adrenal masses. Graded approach to LA1, adherence to strict anatomical principles, minimum handling of the tumor and dissection of the body away from the tumor is the key to success. We suggest that large adrenal masses should be tackled by experienced laparoscopic surgeons.
1. Laparoscopic adrenalectomy: Gaining experience by graded approach. Dalvi A, Thapar P et al. J Minimal Access Surgery 2006;2:59-66
Session: Podium Presentation
Program Number: S005
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