Laparoscopic hand-assisted adrenalectomy for a 20 cm benign tumor

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Laparoscopic hand-assisted adrenalectomy for a 20 cm benign tumor

I. Popescu, V. Tomulescu, D. Hrehoret, A. Popescu, V. Herlea
Cazuri clinice, no. 1, 2007
* Centrul de Chirurgie Generalã si Transplant Hepatic, Institutul Clinic Fundeni
* Centrul de Chirurgie Generalã si Transplant Hepatic


Introduction
Since its introduction, in 1992, by Gagner and Higashihara (2, 3), the laparoscopic approach (LA) has become the method of choice for the resection of both functional and non- functional benign lesions of the adrenal gland. Given the location of the adrenal gland and the vital structures surrounding it, laparoscopic removal is technically facing several potential pitfalls (4), but its minimally invasive nature resulted in increasing benefits for both patients and surgeons. Despite its wide range of possibilities, (5) the open conventional approach involves relatively high rates of morbidity and mortality. Several studies showed that the laparoscopic approach provides more advantages than the open resection of adrenal tumors, including a shorter length of hospitalization, lower costs, faster social recovery and fewer postoperative complications (wound dehiscence, pain related to the incision) (1, 6, 7).
The pathology of the adrenal gland varies from aldosteron or catecholamine hyper secreting tumors (pheocromocytoma) to cortizol secreting tumors and incidentalomas- randomly discovered tumors. The incidence of incidentalomas varies from 4% to 10% in different studies.(8) Random discovery of adrenal lesions along with better imaging procedures raised the issue for the need of surgical resection but also for the type of the approach, depending on certain criteria.
A thorough clinical and biochemical evaluation of patients with adrenal tumors should be taken into account. Adrenalectomy is indicated in cases of benign small functional tumors and those of suspected malignancy (size, morphology on imaging features). Non-functional adrenal tumours are frequently revealed as incidental findings on CT or MR imaging studies undertaken for some other purposes. Removal is imperatively needed when either diagnostic tests identify the presence of a large adrenal mass (>6 cm) or serial examinations show its size enlargement. Such adrenal tumours have an increased risk for malignancy.

Case report
An 18 years old patient was evaluated in another center for body weight gain of 8 kg/year, hypertension (maximal value 170/90 mm Hg), purple striae and alterated mental status. He had a personal history of inguinal hernia operated at the age of 8, urinary calculi, allergy to erythromycin and allergic rhinitis.
Because of the clinical features, Cushing syndrome has been initially suspected. Hormonal measurements revealed: plasma cortisol 8 a.m. 21,8 ug/dl (N.V. 5 -25 ug/dl) with 0,49 ug/dl after low dose dexamethasone suppression, 17 hydroxi-ketosteroids and 17 ketosteroids within normal values. No other hormone measurements were performed. CT scan of the cranium showed the image of a normal pituitary gland.
Ultrasonography showed an abdominal mass of approximately 17 cm without evidence of local invasion. CT scan of the abdomen (fig. 1) confirmed the presence of the adrenal tumor without local invasion, intraabdominal lymphadhenopaty or other lesions.
The patient was subsequently referred to our Department for the surgical removal of the tumor.
At admittance: patient with good general condition; the local abdominal examination showed the presence of a mobile tender mass occupying the left flank and the hypochondrium.
The general examination showed no abnormalities. Normal chest X-ray.
The ultrasound reexamination in our Department described: enlarged left adrenal gland, approximately 17-20 cm diameter, with mix fat and angio component (fine septa with progressive filling), cranial compression of the left kidney, normal parenchyma, and normal aspect of the other intra-abdominal organs.
The surgical indication was mainly determined by the size of the tumor.
The surgical intervention was performed in a scheduled manner, under general anesthesia OIT. The laparoscopic approach was decided, as motivated by the lack of any malignant imaging criteria.

Figure 1
Figure 2
Figure 3

The patient is positioned in a lateral decubitus with the left side up and the left arm extended and suspended.
Access into the peritoneal cavity is made using a Veres needle, a 12-mm trocar is inserted via a supraombilical port (1) and a diagnostic laparoscopy is performed with a 30-degree telescope. As intraoperative assessment in our case showed a left adrenal tumor without evidence of local invasion, a laparoscopic adrenalectomy was started. Three more trocars are inserted under direct vision, in an arcuate shape. The laparoscope is then inserted into the most anterior trocar (3) and the surgeon works laterally with a two hand technique. Mobilizing the colonic flexure is necessary to open the retroperitoneal space and move the colon from the inferior pole of the tumor. The lateral dissection of the spleen at the splenorenal ligament is usually necessary to evaluate the upper pole of the tumor. The dissection was performed with LigaSure Atlass and the spleen and the tail of the pancreas were completely mobilized. Complete mobilization of the tumor was difficult because of its large size and we decided to use a hand assisted technique. We inserted the hand assisted device (HALS) replacing the forth trocar and moving the camera to trocar number 2. So, keeping laterally the tumor with the hand, we gained access to the medial and upper part of the tumor in order to dissect and section (with LigaSure) the adrenal vessels. Extraction of the tumor imposed fracturing it in a large bag, used for organ transport in transplant, because the hand-assisted port only measures 8 cm in diameter. Control of bleeding, drainage and closing the HALS and trocars ports ended the operation.
Figure 2 shows the aspect of the resected specimen aspect and figure 3 describes the trocars and HALS port placement.
The procedure lasted 4 hours and with no intraoperative complications.
Postoperative evolution was simple, with early recovery of digestive tolerance, and no fever. Minimal local wound infection was noted and treated conservatively.
On the 5-th postoperative day, the drainage revealed pancreatic fistula -150 ml/day (fluid lipase > 1000 U/l). Plasma lipase and amylase ranged within normal limits. The fistula most likely occurred during the mobilization of the tumor by injuring the pancreatic tail.
Conservative Somatostatin treatment led to the closing of the fistula 21 days after surgery.
The patient was discharged 11 days after the intervention, maintaining the drain (suppressed 21 days after surgery). All biochemical tests showed normal values.
The histopathological examination of the tumor: ganglio-neuroma (fig. 4a) of the adrenal gland (tumor size 20 cm, weight 670 g).
Immunohistochemistry confirmed the histopathology result (fig. 4b).
Three months after the intervention, the evaluation showed: general examination within normal limits and normal blood pressure. Abdomen, chest and pelvis CT scan revealed a normal postoperative aspect without evidence of local or distal recurrence. All the findings point to the likelihood of a hormonally active tumour (most probably, androgenic hormones), which is confirmed by the absence of any of the symptoms after the resection.

Figure 4A
Figure 4B
Figure 5

Discussion
The present report enabled us to show that laparoscopic adrenalectomy could be a safe and effective intervention even for the treatment of large tumors, with long term results similar to the conventional open procedures. Good know-ledge of the anatomy and physiology of the adrenal gland allowed a minimal invasive resection of a 20 cm tumor. Complications were minimal and could be effectively managed by conservative treatment.
Although the laparoscopic approach of the adrenal is an internationally accepted standard procedure, the latest studies recommend that laparoscopic resection should be used for adrenal tumors with highest size limits ranging between 10 cm and 15 cm, with variations. Traditionally, any tumor larger than 6 cm showed a higher risk of malignancy (10%),(9, 10) while a tumor size over 8 cm raised the risk to 47%.(11, 12) Only one study in the literature reported the case of laparoscopic resection of a benign 22 cm adrenal tumor.(1)
Given the current technological advances in imaging, the laparoscopic approach was extended to the treatment of larger tumors without evidence of CT scan malignant criteria (local invasion, regional or distant lymphadenopathy).
The present case has particular characteristics related to the size of tumor, the laparoscopic approach and the histo-pathological finding. Ganglioneuroma is a rare benign tumor originating from the neural crest tissue of the sympathetic nervous system. It belongs to the group of neurogenic tumors that includes also ganglioneuroblastoma and neuroblastoma. The retroperitoneum is the first or second most common location (32-52%), very rarely related to the adrenal gland.(13) Clinically it is often asymptomatic, even for large tumours, showing non-specific abdominal pain and the presence of an abdominal mass identified by palpation. Hormonally active forms have been reported: VIP, catecholamine and androgenic hormones explain such symptoms as hypertension, diarrhea and virilization.(8)
Laparoscopic adrenalectomy provides important benefits: reduced postoperative pain, lower costs, shorter hospital stay, fewer surgical wound complications than the open procedure, and improved esthetic results.(6, 7, 14) The hand-assisted alternative allows not only an accurate manipulation of tumor and adrenal gland (the main issue of adrenal laparoscopic approach), but also a good digital control of blood vessels that can be very large when large size tumors are present. The approach also enables an easy extraction of the tumor, with constant protection of abdominal wall wounds (fig. 5).
In all cases of adrenal tumors, clinical, biochemical, and imagistic evaluations before and after the intervention must be made, and any evidence of malignancy imposes immediate conversion to an open procedure. With the growing surgeons' experience in this particular field, we expect that several advantages will be soon noticed, including a shorter operative time, reduced complications rates and broader indication for surgery, while the laparoscopic approach of malignant adrenal lesions remains a matter of considerable international debate. In case of large tumors or complex operations, hand-assisted devices may add the comfort of tactile feeling and gentle manipulation.

Reference List
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