Surgery of the adrenals

Adrenal gland surgeries techniques

1. Surgery of the Adrenal Glands Dr. Oladele Situ Snr. Registrar in Surgery National Hospital Abuja November 10, 2020

2. Outlines History Surgical anatomy Indications for Adrenalectomy Contraindications Pre-operative work up Approches to adrenalectomy Open Laparoscopic Laparo-endoscopic single site (LESS) Natural Orifice Transluminal Endoscopic Surgery (NOTES) Hand assisted Robotic Ablative techniques Partial adrenalectomy Complications Local experience

3. History Knowsly Thornton removed a 20-pound left adrenal mass with the left kidney in 1889 Charles Mayo performed the first flank adrenalectomy for pheochromocytoma in 1927 Young described the “hocky stick” posterior approach in 1936 while Chute et al. described the thoracoabdominal approach in 1949 Gagner et al were the fist to perform laparoscopic adrenalectomy in 1992 Robot-assisted laparoscopic adrenalectomy was described Piazza et al and Hubens et al in 1999.

4. Surgical anatomy The right adrenal vein is a potentially perilous structure to manage, because it is short , wide , variable , and confluent with thin-walled , large capacitance vessels . A significant second adrenal vein may be found in up to 10% of patients. In the right AVOID BLEEDING , in the Left GET THE PLANE RIGHT !

5. Variations in the right adrenal veins

6. Indications and contraindications for Adrenalectomy Absolute Contra-indications to adrenalectomy: Extensive metastatic disease Uncontrolled coagulopathy Severe cardiopulmonary disease that precludes anaesthesia Size of adrenal mass and risk of malignancy: <4cm = <2% 4-6cm = about 6% >6cm = up to 25%

7. Making the decision to operate Incidentalomas make up 1-4% of all abdominal images Plasma aldosterone concentration ( PAC )/ Plasma renin activity ( PRA ) can help rule out conn’s Suspicious CT features : heterogenicity, high attenuation rate, irregular margins

8. DDx of adrenal incidentaloma

9. Pre-operative work up History & exam: Age and obesity Is it a functional adrenal mass? What is the likelihood of malignancy? Past surgical/medical history preventing laparoscopy Primary or recurrence? Comorbidities like HTN, DM, etc Consent for Nephrectomy! Diagnosis and work up: Contrasted CT/ MRI ( where is the site and what size is it? ) CXR Serum cortisol and DST Urinary metanephrines FBC EUCr * Clotting and LFT GXM-HTN + vascularity *malignant Pheochromocytomas are poorly responsive to chemotherapy or radiotherapy hence surgery is mainstay of treatment.

10. Specific Peri-Op concerns Close sugar monitoring in Cushing's disease and watch out for adrenal insufficiency Close BP, EUCr monitoring in patients with Conn's and pheochromocytoma Phenoxybenzamine 10mg b.d (max 40mg t.i.d ) reverse chronic α-receptor downregulation aldosterone antagonist ( spironolactone ) should be started at least 1 to 2 weeks before surgery in Conn’s dx Norepinephrine, Na + Nitroprusside, lidocain CVL monitoring, PPIs , prokinetics NG tube, urethral catheter & DVT care

11. Open Adrenalectomy Indications Approaches Transperitoneal Anterior trans abdominal Thoraco-abdominal (lateral) Retroperitoneal Flank approach (lateral) Posterior lumbodorsal Anaesthesia : General anaesthesia

12. Open Adrenalectomy: Positioning for left lateral transabdominal laparoscopic adrenalectomy For posterior lumbodorsal approach

13. Open Adrenalectomy: Access to both adrenals Anterior transperitoneal approach Posterior lumbodorsal approach 11 th or 12 th rib may have to be excised. Ablasion procedures 5cm from midline

14. Open Adrenalectomy: Access to a single adrenal Thoraco-abdominal approach (Thoraco-abdominal) Between the 8 th and 9 th ribs into the rectus abdominis. Facilitate mobilization of the liver in large tumours

15. Open adrenalectomy: flank incision Gaining access over the 11 th rib Excise rib, protect neurovascular bundle

16. Intra-operative manipulations: Left Adrenals Anterior transperitoneal approach Anterior transperitoneal approach Mixter forceps

17. Intra-operative manipulations: right adrenals Anterior –transperitoneal approach Adrenal tumour invading the IVC

18. Intra-operative manipulations: right adrenals Specimen with IVC IVC repaired with PTFE

19. Open adrenalectomy: Wound closure Ensure dry bed, drain not necessary Wound closed in layers: Absorbable for muscles, rib re-approximation in the flanks with absorbable non-absorbable prolene for costal cartilage Subcute closure Skin closure Need for CTTD ?

20. Oncologic principles of resection of adrenocortical carcinoma 1. No touch technique 2. Preservation of the intact peritoneum on the anterior surface of the adrenal gland if no evidence of invasion through the overlying peritoneal layer 3. En - bloc resection of tumor with a wide margin of surrounding benign tissue outside the tumor capsule 4. Strict preservation of an intact tumor capsule 5. Exclusion of the remainder of the peritoneal cavity as much as possible using barriers such as laparotomy pads, plastic barriers, or drapes 6. Minimizing of bleeding and fluid spillage into the peritoneal cavity 7. Change of gloves, gowns, and instruments after removal of the tumor and prior to closure of the abdomen.

21. Laparoscopic Adrenalectomy (90%): Trans-peritoneal Approach-Full lateral or modified lateral (45-60 O ) Right left Palmer’s point

22. Laparoscopic Adrenalectomy: Trans-peritoneal

23. Laparoscopic Adrenalectomy: dorsal retroperitoneal approach Dorsal (laparoscopic) retroperitoneal

24. Laparoscopic Adrenalectomy: lateral retro-peritoneal Approach Lateral (laparoscopic) retroperitoneal

25. Intra-Op technicalities Pneumoperitoneum Gasless laparoscopy LaparoTenser ® Balloon dissection 1.5cm stab incision o Camera then 30 o camera Harmonic, ligasure , electrocautery Surgeon and assistant faces camera Usually no need for drain Open conversion: Bleeding, tumour size, tumour thrombus, pancreatic injury

26. Laparoscopic Adrenalectomy: Left adrenal 1 2 3 4

27. Laparoscopic adrenalectomy: Right adrenal

28. Gasless Laparoscopic adrenalectomy

29. Robotic Adrenalectomy Advantages: Better ergonomics & EndoWrist ® Better magnification Tremor filtering Disadvantages: Cost Learning curve Slower Allow 8cm between robot hands

30. Other Approaches to adrenalectomy Hand-Assisted laparoscopic Getting out of favour due to robotic May still be indicated in difficult laparoscopic procedure Laparo-endoscopic single site (LESS) Similar to laparoscopic Small (< 4cm) can be removed ? Better cosmesis However poor tool triangulation and tissue retraction ↑operation time and ?↑risk of injury

31. Other Approaches to adrenalectomy NOTES-assisted Adrenalectomy Largely experimental First described in 2008 by Fritscher -Ravens et al. Trans esophago-gastric Trans vaginal Robotic assisted

32. Post Op care Clos vitals and sugar monitoring Close EUCR monitoring Bowel function returns in about 2-3 days in open surgery Analgesia and antibiotics Hydrocortisone tapered down 50mg/day Can be discharge in day 1 in laparoscopic procedure or up to day day 7 in open procedure.

33. Partial adrenalectomy To avoid adrenal insufficiency and permanent fixed steroid dosing Patient requiring bilateral adrenalectomy, solitary adrenal gland, familial syndromes e.g. MEN IIA, Familial pheochromocytoma, VHL dx Resect tumour without mobilizing gland Intra-op USS may be required for tumours <1cm, or to confirm completeness of resection ? ≥ 20% of the gland must be left to prevent adrenal insufficiency

34. Ablative surgery for Adrenal gland RFA HIFU Cryo-ablation Both RFA and HIFU has a risk of dangerous catecholamine release

35. Complications of adrenalectomy Intraoperative Post operative

36. Any controversy Laparoscopy > open Retroperitoneal approach > transperitoneal approach Lap > Robot (cost) Any advantage of LESS? Any use for NOTES? Is α-blockade always necessary?

37. Local experience and conclusion NHA Indications for adrenalectomy are clear. Surgery is mandated for functional adrenal tumours Size and nature of the tumour is a critical determinant of the access Perioperative mortality from pheochromocytoma in specialised centres is now< 1%, 90% done laparoscopically Adrenocortical carcinoma is rare, open approach favoured.

38. Thank you