CN Parnaby, JT Jenkins, PJ O’Dwyer
Department of Surgery, Western Infirmary, Glasgow
Corresponding Author: Craig Parnaby
email: craigparnaby@aol.com
SMJ 2008 53(2): 65
Background
Since it was first introduced in 19921, laparoscopic adrenalectomy has been shown to demonstrate benefits in terms of safety, recovery, analgesic requirements and hospital stay when compared to the traditional open procedure.2-4 Laparoscopic adrenalectomy has become the procedure of choice for most adrenal pathologies. However, if a locally invasive adrenal tumour is suspected at time of laparoscopy, conversion to an open surgery is recommended to ensure a wide radical resection.5
We report a radical laparoscopic adrenalectomy and en-bloc nephrectomy in a 51 year old male with locally advanced adrenal carcinoma. This case represents the 128th LA by the operating surgeon (POD). Long-term experience with laparoscopic nephrectomy (since 1994) and knowledge of the retroperitoneal anatomy also exist.
Case
Report
A 51 year old man initially presented with right sided abdominal pain and weight loss. An abdominal computed tomography (CT) identified a 5cm right adrenal tumour with evidence of heterogeneity and irregular margins (Figure 1). Endocrine assessment had demonstrated a low grade cortisol producing tumour. There was no family history of adrenal carcinoma and he gave a history of narcotic drug abuse. He was referred for laparoscopic adrenalectomy. At time of laparoscopy the adrenal tumour was felt to be invading the upper pole of the right kidney. Macroscopic appearances were consistent with a locally invasive adrenal carcinoma. After thorough assessment, a decision was made to perform a laparoscopic adrenalectomy with en-bloc radical laparoscopic nephrectomy. This was achieved without complication and minimal blood loss. The resected specimen was removed through a transverse incision using a wound protector. The total anaesthetic time was 140 minutes. There were no post-operative complications and the patient was discharged on the second post-operative day. Histology appearances were consistent with adrenal cortical carcinoma with fat necrosis within the perinephric fat.6 The carcinoma appeared to be completely excised.
Figure 1: CT image of right adrenal tumour (arrow) highlighting proximity to upper pole of right kidney
After follow-up of 9 months there has been no clinical or radiological evidence of local recurrence or distant metastases.
Discussion
Laparoscopic adrenalectomy is indicated for the majority of adrenal tumours.5 Local invasion of the adrenal tumour is regarded as one of the few contraindications to the laparoscopic approach. This is mainly due to the extent and complexity of the laparoscopic resection required.7
We agree with other series if dense adhesions and invasion into the nearby vascular structures are identified, an open procedure is indicated in order to control the inferior vena cava, aorta, splenic or renal veins.8 However, if local invasion is suspected to involve the kidney only, a radical adrenalectomy with clear resection margins should be feasible. Laparoscopic surgery allows an excellent view of large tumours and radical resection with low blood loss can be performed without the need for large incisions.
In this case, after thorough laparoscopic assessment, local invasion was suspected to involve upper pole of the kidney only. A successful radical laparoscopic adrenalectomy was then performed. There has been no evidence of local recurrence after a follow-up of 9 months. Other series have shown local recurrence usually occurs within a few months, even after successful resection of adrenal carcinoma.9
This case report has demonstrated the feasibility and safety of performing a radical laparoscopic adrenalectomy for a locally invasive adrenal tumour. Unless radiological imaging clearly identifies extensive local invasion, we feel it is important to perform initial diagnostic laparoscopy to assess the suitability of resection. This strategy would prevent patients undergoing unnecessary open procedures and allow the benefits of laparoscopy. However, if there is any concern over incomplete resection, there should be a low threshold for conversion to open surgery.
Advanced
laparoscopic skills, a sound knowledge of retroperitoneal anatomy and experience
in adrenal surgery are essential in order to adopt this approach.
References
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