Operative considerations and technique for transperitoneal laparoscopic partial/subtotal adrenalectomy

Amani Munshi, MD, Elliot J Mitmaker, MD, MSc, FRCSC, Liane S Feldman, MD, FRCSC, FACS. McGill University Health Centre

We present here a review of the preoperative considerations and technique for laparoscopic transperitoneal partial adrenalectomy, also referred to as a subtotal adrenalectomy. This is more recently used as an alternative approach to complete bilateral adrenalectomies in patients with inheritable causes of adrenal tumors, including Von Hippel Lindau syndrome, MEN2a and neurofibromatosis. Bilateral complete adrenalectomies result in a lifelong need for exogenous steroids and it does not entirely eliminate the risk of recurrence. Pheochromocytomas seen in inheritable syndromes are associated with a low risk of malignancy. Hence a complete resection is not mandatory. Partial or subtotal resections have been shown to have similar operative time, blood loss and a comparable cure rate to a complete resection. The rate of local recurrence is also comparable. To have adequate adrenal function approximately 10-30% of adrenal tissue is estimated to be required and there is a reported steroid dependence rate post-operatively of up to 35%.

This is a case report on a 22 year old female patient with Von Hippel Lindau syndrome. On screening, she was found to have bilateral adrenal tumors, 6 cm on the left and 2.5 cm on the right, biochemically consistent with pheochromocytomas. She previously underwent a complete left adrenalectomy and now presented for a partial resection on the right side. We present a video showing the key operative steps. We begin by mobilizing the right lobe of the liver. Preoperative imaging studies showed the tumor at the superior medial aspect and the portion bordering the kidney was planned to be preserved. Hence the dissection is begun at the superior medial aspect of the adrenal gland. The adrenal vein is ligated. The tumor is mobilized off the retroperitoneum ligating the small feeding vessels, taking care to ensure the attachments to the portion staying are not ligated to avoid devascularization. Laparoscopic ultrasound is done to ensure no other lesions are present that were not seen on the preoperative CT imaging. The adrenal gland is ligated using an ultrasonic dissector, leaving a small margin of normal tissue on the tumor.

The key points for the procedure are summarized. These include adequate preoperative imaging to assess for location of the tumor and to identify the portion of the adrenal to be spared. These partial resections are only possible for smaller lesions with some normal adrenal tissue remaining. Ligation of the adrenal vein is done based on its proximity to the tumor. Minimal mobilization of the portion staying is done to avoid devascularization. Intraoperative ultrasound is performed to rule out any additional smaller lesions not seen on prior imaging. A small margin of adrenal tissue is taken along with the tumor, ligating with an ultrasonic dissector or a stapling device.

Final pathology for our patient showed negative margins. She was placed on a steroid taper and discharged. An ACTH stimulation test was done 3 weeks post op and showed decreased adrenal reserve. She will undergo repeat testing in a few weeks prior to withdrawal of exogenous steroids.

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